1up Electronic Prior Authorization (ePA)

Designed to meet CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) requirements and leveraging industry standards, 1up Prior Authorization APIs automate the prior authorization process using standard FHIR®-based APIs to connect in-network providers with your prior authorization rules and existing utilization management systems.

Our solution enables providers to confirm whether prior authorization is necessary for a given service or procedure, verify member coverage, discover specific prior authorization documentation requirements, and submit a prior authorization request to your utilization management system.

1up's Electronic Prior Authorization conforms to the Da Vinci Burden Reduction specifications with the following three implementation guides:

• Coverage Requirements Discovery (CRD)
• Documentation Templates and Rules (DTR)
• Prior Authorization Support (PAS)

The CRD API is used to perform the first step of the Electronic Prior Authorization process. The provider's Clinical Decision Support (CDS) client, such as their EMR or appointment scheduling software, sends a CDS Hooks request to 1upHealth’s CRD API.

The response informs the provider whether prior authorization is required and if the member is covered by the plan.

The DTR API is used to perform the second step of the Electronic Prior Authorization process. The provider's CDS client sends a request to 1upHealth’s DTR API.

The response provides the CDS application with a questionnaire to complete and reference in the PAS API request.

The PAS API is used to perform the third step of the Electronic Prior Authorization process. The provider's CDS client sends a request to 1upHealth’s PAS API. The request bundle includes clinical information and supporting documentation.

The server may respond with a prior authorization decision. The server may also respond without an approval or denial decision and instead indicate that further review is required.