# Prior Authorization Support (PAS) ## What is PAS? 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](https://build.fhir.org/ig/HL7/davinci-pas/) ### Supported versions 1upHealth supports the following versions of the HL7 Da Vinci Prior Authorization Support Implementation Guide: * STU 2.0.1 ## How FHIR-native PAS works PAS defines a FHIR-based workflow that bridges providers and payers with 1up as an intermediary: 1. **Construct request bundle**: Provider system builds a PAS Request Bundle containing the Claim, Patient, Coverage, ordering Practitioner, and supporting clinical resources. 2. **Submit via $submit**: EHR sends a request to the `$submit` endpoint on 1up's PAS API with the request bundle. 3. **Payer processing**: Payer evaluates the request against coverage rules and clinical criteria. This can be a manual or automated process. 4. **Payer Response**: Payer's system provides a FHIR ClaimResponse. 5. **EHR receives decision**: Provider system receives the authorization decision (approved, denied, or pended). ## How X12 PAS works Coming soon! Documentation about X12 PAS is coming soon! **Specification**: [PAS Workflow](https://build.fhir.org/ig/HL7/davinci-pas/specification.html) ## Key Operations ### `$submit` Submits a prior authorization request bundle to 1up as an intermediary for processing. **Endpoint**: `POST https://gateway.1up.health/v1/1uphealth-core-prod/pas-prod/{customerKey}/{partitionKey}/Claim/$submit` Path parameters Replace the `{customerKey}` and `{partitionKey}` path parameters with the appropriate values for the desired payer. Refer to [Provider implementation](/docs/epa/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 quantities - `Patient`: Member demographics and identifiers - `Coverage`: Insurance plan and subscriber information - `Practitioner` / `PractitionerRole`: Ordering and rendering providers - `Organization`: 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](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-request-bundle.html) **Output**: A PAS Response Bundle containing: - `ClaimResponse`: Authorization decision with status and review reasons - Updated references to submitted resources **Specification**: [Claim-submit Operation](https://build.fhir.org/ig/HL7/davinci-pas/OperationDefinition-Claim-submit.html) ### `$inquire` Checks the current status of a previously submitted and pended prior authorization request. **Endpoint**: `POST https://gateway.1up.health/v1/1uphealth-core-prod/pas-prod/{customerKey}/{partitionKey}/Claim/$inquire` Path parameters Replace the `{customerKey}` and `{partitionKey}` path parameters with the appropriate values for the desired payer. Refer to [Provider implementation](/docs/epa/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 number - `Patient` - The member/beneficiary - `Coverage` - Insurance coverage **Output**: A PAS Inquiry Response Bundle containing: - `ClaimResponse` - Current authorization status **Specification**: [Claim-inquiry Operation](https://build.fhir.org/ig/HL7/davinci-pas/OperationDefinition-Claim-inquiry.html) ## Subscription The [PAS Subscription profile](https://build.fhir.org/ig/HL7/davinci-pas/en/StructureDefinition-profile-subscription.html) is planned for support and coming soon. ## Response Structure The PAS Response Bundle contains a `ClaimResponse` resource with the authorization decision. **Key ClaimResponse fields**: - `outcome`: The processing result. The options are `complete`, `queued` (pended), or `error`. - `preAuthRef`: Prior authorization number (when approved) - `item.adjudication`: Per-item decisions with review action codes - `reviewAction`: 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 `$inquire` to check status later | | Partial | Some items approved, others denied or pended | | Cancelled | Previously approved authorization has been cancelled | **Specification**: [PAS Response Bundle](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-response-bundle.html) ## FHIR Resource Profiles ### Core Profiles **PAS Claim** - [PAS Claim Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-claim.html): Represents the prior authorization request with service codes, dates, and supporting information references **PAS ClaimResponse** - [PAS ClaimResponse Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-claimresponse.html): Contains the authorization decision, PA number, and review action details ### Bundle Profiles **PAS Request Bundle** - [PAS Request Bundle Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-request-bundle.html): Input to `$submit` containing Claim and all supporting resources **PAS Response Bundle** - [PAS Response Bundle Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-response-bundle.html): Output of `$submit` containing ClaimResponse **PAS Inquiry Request Bundle** - [PAS Inquiry Request Bundle Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-inquiry-request-bundle.html): Input to `$inquire` **PAS Inquiry Response Bundle** - [PAS Inquiry Response Bundle Profile](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-pas-inquiry-response-bundle.html): Output of `$inquire` ### Supporting Resource Profiles **Patient and Coverage** - [PAS Beneficiary Patient](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-beneficiary.html) - [PAS Coverage](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-coverage.html) **Providers and Organizations** - [PAS Practitioner](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-practitioner.html) - [PAS PractitionerRole](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-practitionerrole.html) - [PAS Organization](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-organization.html) - [PAS Insurer Organization](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-insurer.html) - [PAS Requestor Organization](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-requestor.html) **Order Resources** - [PAS ServiceRequest](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-servicerequest.html) - [PAS DeviceRequest](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-devicerequest.html) - [PAS MedicationRequest](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-profile-medicationrequest.html) See [all PAS resource profiles](https://build.fhir.org/ig/HL7/davinci-pas/artifacts.html#structures-resource-profiles) ## Examples Complete request/response examples from HL7: - [Prior Authorization Request Bundle - Surgical](https://build.fhir.org/ig/HL7/davinci-pas/Bundle-ReferralAuthorizationBundleExample.html): Surgical procedure authorization request - [Prior Authorization Request Bundle - Referral](https://build.fhir.org/ig/HL7/davinci-pas/Bundle-ReferralAuthorizationBundleExample.html): Referral authorization request - [Prior Authorization Response Bundle](https://build.fhir.org/ig/HL7/davinci-pas/Bundle-ReferralAuthorizationResponseBundleExample.html): Approved response - [Inquiry Request Bundle](https://build.fhir.org/ig/HL7/davinci-pas/Bundle-ReferralPendingAuthorizationResponseBundleExample.html): Status inquiry for pended request - [MedicationRequest Example](https://build.fhir.org/ig/HL7/davinci-pas/MedicationRequest-MedicationRequestExample.html): Medication prior authorization - [Error Response Example](https://build.fhir.org/ig/HL7/davinci-pas/Bundle-ErrorResponseBundleExample.html): Error/rejection response See [all PAS examples](https://build.fhir.org/ig/HL7/davinci-pas/artifacts.html#example-example-instances) ## PAS Extensions | Extension | Purpose | Specification | | --- | --- | --- | | `reviewAction` | Conveys the payer's review decision (approved, denied, pended) | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-reviewAction.html) | | `reviewActionCode` | Specific review action code from X12 code list | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-reviewActionCode.html) | | `itemPreAuthIssueDate` | Date the prior authorization was issued | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-itemPreAuthIssueDate.html) | | `itemPreAuthPeriod` | Authorized date range for the service | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-itemPreAuthPeriod.html) | | `administrationReferenceNumber` | Payer-assigned tracking number | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-administrationReferenceNumber.html) | | `certificationType` | Type of certification (initial, renewal, extension) | [Spec](https://build.fhir.org/ig/HL7/davinci-pas/StructureDefinition-extension-certificationType.html) | See [all PAS extensions](https://build.fhir.org/ig/HL7/davinci-pas/artifacts.html#structures-extension-definitions)