Prior Authorization Support (PAS) enables providers to submit prior authorization requests electronically using FHIR, replacing phone, fax, and portal-based workflows.
Official specification: HL7 Da Vinci Prior Authorization Support Implementation Guide
1upHealth supports the following versions of the HL7 Da Vinci Prior Authorization Support Implementation Guide:
- STU 2.0.1
PAS defines a FHIR-based workflow that bridges providers and payers with 1up as an intermediary:
- Construct request bundle: Provider system builds a PAS Request Bundle containing the Claim, Patient, Coverage, ordering Practitioner, and supporting clinical resources.
- Submit via $submit: EHR sends a request to the
$submitendpoint on 1up's PAS API with the request bundle. - Payer processing: Payer evaluates the request against coverage rules and clinical criteria. This can be a manual or automated process.
- Payer Response: Payer's system provides a FHIR ClaimResponse.
- EHR receives decision: Provider system receives the authorization decision (approved, denied, or pended).
Documentation about X12 PAS is coming soon!
Specification: PAS Workflow
Submits a prior authorization request bundle to 1up as an intermediary for processing.
Endpoint: POST https://gateway.1up.health/v1/1uphealth-core-prod/pas-prod/{customerKey}/{partitionKey}/Claim/$submit
Replace the {customerKey} and {partitionKey} path parameters with the appropriate values for the desired payer. Refer to Provider implementation for more details about these path parameters.
Input: The PAS Request Bundle must contain at least the following resources:
Claim: Prior authorization request with procedure/service codes, dates, and quantitiesPatient: Member demographics and identifiersCoverage: Insurance plan and subscriber informationPractitioner/PractitionerRole: Ordering and rendering providersOrganization: Requesting and servicing organizations- Order resources (
ServiceRequest,DeviceRequest,MedicationRequest): What is being requested. Only one of the three order resources is required.
Supporting info resources (QuestionnaireResponse, Condition, Observation), which contain clinical documentation, are optional.
Specification: PAS Request Bundle
Output: A PAS Response Bundle containing:
ClaimResponse: Authorization decision with status and review reasons- Updated references to submitted resources
Specification: Claim-submit Operation
Checks the current status of a previously submitted and pended prior authorization request.
Endpoint: POST https://gateway.1up.health/v1/1uphealth-core-prod/pas-prod/{customerKey}/{partitionKey}/Claim/$inquire
Replace the {customerKey} and {partitionKey} path parameters with the appropriate values for the desired payer. Refer to Provider implementation for more details about these path parameters.
Input: A PAS Inquiry Request Bundle containing:
Claim- With the original claim identifier or prior authorization numberPatient- The member/beneficiaryCoverage- Insurance coverage
Output: A PAS Inquiry Response Bundle containing:
ClaimResponse- Current authorization status
Specification: Claim-inquiry Operation
The PAS Subscription profile is planned for support and coming soon.
The PAS Response Bundle contains a ClaimResponse resource with the authorization decision.
Key ClaimResponse fields:
outcome: The processing result. The options arecomplete,queued(pended), orerror.preAuthRef: Prior authorization number (when approved)item.adjudication: Per-item decisions with review action codesreviewAction: Overall review outcome (approved, denied, pended, partial, cancelled)error: Error details if the request was rejected
Authorization outcomes:
| Outcome | Meaning |
|---|---|
| Approved | Authorization granted; preAuthRef contains the PA number |
| Denied | Authorization denied; review reasons provided |
| Pended | Additional review needed; use $inquire to check status later |
| Partial | Some items approved, others denied or pended |
| Cancelled | Previously approved authorization has been cancelled |
Specification: PAS Response Bundle
PAS Claim
- PAS Claim Profile: Represents the prior authorization request with service codes, dates, and supporting information references
PAS ClaimResponse
- PAS ClaimResponse Profile: Contains the authorization decision, PA number, and review action details
PAS Request Bundle
- PAS Request Bundle Profile: Input to
$submitcontaining Claim and all supporting resources
PAS Response Bundle
- PAS Response Bundle Profile: Output of
$submitcontaining ClaimResponse
PAS Inquiry Request Bundle
- PAS Inquiry Request Bundle Profile: Input to
$inquire
PAS Inquiry Response Bundle
- PAS Inquiry Response Bundle Profile: Output of
$inquire
Patient and Coverage
Providers and Organizations
- PAS Practitioner
- PAS PractitionerRole
- PAS Organization
- PAS Insurer Organization
- PAS Requestor Organization
Order Resources
Complete request/response examples from HL7:
- Prior Authorization Request Bundle - Surgical: Surgical procedure authorization request
- Prior Authorization Request Bundle - Referral: Referral authorization request
- Prior Authorization Response Bundle: Approved response
- Inquiry Request Bundle: Status inquiry for pended request
- MedicationRequest Example: Medication prior authorization
- Error Response Example: Error/rejection response
See all PAS examples
| Extension | Purpose | Specification |
|---|---|---|
reviewAction | Conveys the payer's review decision (approved, denied, pended) | Spec |
reviewActionCode | Specific review action code from X12 code list | Spec |
itemPreAuthIssueDate | Date the prior authorization was issued | Spec |
itemPreAuthPeriod | Authorized date range for the service | Spec |
administrationReferenceNumber | Payer-assigned tracking number | Spec |
certificationType | Type of certification (initial, renewal, extension) | Spec |