You can use this API action if your organization is a payer or heath tech vendor that processes and responds to preauthorization requests. Typically, you can use this API action for:
- approving or declining preauthorization requests; or
- streamlining or digitizing your process for receiving preauthorization requests.
Check out our case study for more details about the problems you can solve with this API action.
To kick off your workflow, your connection must submit a preauthorization request.
You can use this API action with a query-based API that can also exchange X12. Your responses to preauthorization requests can be either synchronous or asynchronous, depending on your own system’s capabilities.
Redox supports exchanging preauthorizations for either services or prescriptions, so you can respond to both kinds of requests.
We recommend that you review the Claim$submit-preauthorization schema to make sure you can support all the required data points to receive a preauthorization request and that it contains all the data you would require to process and approve a preauthorization request.
HIPAA uses the X12 data standard, so your connection must use Current Procedural Terminology (CPT) codes to designate outpatient services or procedures included in the preauthorization request. For medication, equipment, or supplies for treatment, your connection must use Healthcare Common Procedure Coding System (HCPCS), Level II codes. Make sure that you can support each of these codesets.
You receive preauthorization data within the FHIR® Claim resource. While we generally support filters to reduce unwanted messages (learn more about filters), we don’t support applying comprehensive business logic or rules to incoming Claim data.
What's next?
Does this API action seem like a good fit for your unique workflow? If so, let your Redox rep know! You can begin development by downloading the relevant resource schema (which is noted in the relevant action step below), and deciding which data elements you need. Then head over to our Quickstart guide to dive right in.
If you're not engaged with our sales team yet, talk to a Redoxer to get started.
In order to receive and process medication preauthorization requests, you must be able to support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that that processing looks like, but when you're ready to respond.
Make sure to include whether your connection's request is accepted, pending, or declined.
{"id": "RedoxClaimResponseBundleComprehensiveExample","type": "collection","entry": [{"resource": {"id": "RedoxPAClaimResponseExample","use": "preauthorization","item": [{"extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber","valueString": "REF456"},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate","valueDate": "2021-08-23"},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod","valuePeriod": {"end": "2021-09-23","start": "2021-08-23"}},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber","valueIdentifier": {"value": "23462346"}},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail","extension": [{"url": "productOrServiceCode","valueCodeableConcept": {"text": "Right heart catheterization","coding": [{"code": "93451","system": "http://www.ama-assn.org/go/cpt"}]}},{"url": "quantity","valueQuantity": {"value": 1}},{"url": "unitPrice","valueMoney": {"value": 4966,"currency": "USD"}}]}],"adjudication": [{"category": {"coding": [{"code": "submitted","system": "http://terminology.hl7.org/CodeSystem/adjudication"}]},"extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction","extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode","valueCodeableConcept": {"coding": [{"code": "A1","system": "https://codesystem.x12.org/005010/306","display": "Certified in total"}]}},{"url": "number","valueString": "AUTH1001"}]}]}],"itemSequence": 1}],"type": {"coding": [{"code": "professional","system": "http://terminology.hl7.org/CodeSystem/claim-type"}]},"status": "active","created": "2021-08-23T16:35:54.648Z","insurer": {"reference": "Organization/RedoxPAInsurerOrganizationExample"},"outcome": "complete","patient": {"reference": "Patient/RedoxPABeneficiaryExample"},"request": {"reference": "Claim/RedoxPAServiceClaimExample","identifier": {"type": {"coding": [{"code": "ClaimID"}]},"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"}},"requestor": {"reference": "Organization/RedoxPARequestorOrganizationExample"},"processNote": [{"text": "Covered under extended benefits"}],"resourceType": "ClaimResponse"}},{"resource": {"id": "RedoxPABeneficiaryExample","name": [{"given": ["Timothy","Paul"],"family": "Bixby"}],"gender": "male","birthDate": "2008-01-06","identifier": [{"value": "M23462346","system": "urn:redox:MRN"}],"resourceType": "Patient"}},{"resource": {"id": "RedoxPACoverageWithRelatedSubscriberExample","class": [{"type": {"coding": [{"code": "group","system": "http://terminology.hl7.org/CodeSystem/coverage-class"}]},"value": "GRP2245"}],"payor": [{"reference": "Organization/RedoxPAInsurerOrganizationExample"}],"status": "active","subscriber": {"reference": "RelatedPerson/RedoxPASubscriberExample"},"beneficiary": {"reference": "Patient/RedoxPABeneficiaryExample"},"resourceType": "Coverage","subscriberId": "M2346623"}},{"resource": {"id": "RedoxPARequestorOrganizationExample","name": "Good Health Clinics","active": true,"address": [{"city": "Madison","line": ["123 Main St."],"state": "WI","country": "USA","district": "Dane","postalCode": "53703"}],"resourceType": "Organization"}},{"resource": {"id": "RedoxPAInsurerOrganizationExample","name": "Aetna","active": true,"address": [{"city": "Lexington","line": ["PO Box 14080"],"state": "KY","country": "USA","district": "Fayette","postalCode": "40512-4079"}],"resourceType": "Organization"}},{"resource": {"id": "RedoxPAPractitionerRoleExamplePat","location": [{"display": "1st Street Family Clinic"}],"specialty": [{"coding": [{"code": "394579002","system": "http://snomed.info/sct","display": "Cardiology"}]}],"organization": {"reference": "Organization/RedoxPARequestorOrganizationExample"},"practitioner": {"reference": "Practitioner/RedoxPAPractitionerExamplePat"},"resourceType": "PractitionerRole"}},{"resource": {"id": "RedoxPAPractitionerExamplePat","name": [{"given": ["Pat"],"family": "Granite"}],"address": [{"city": "Madison","line": ["123 Main St."],"state": "WI","country": "USA","district": "Dane","postalCode": "53703"}],"telecom": [{"value": "+16085551234"}],"identifier": [{"value": "4356789876","system": "http://hl7.org/fhir/sid/us-npi"}],"resourceType": "Practitioner"}},{"resource": {"id": "RedoxPASubscriberExample","name": [{"given": ["Barbara"],"family": "Bixby"}],"patient": {"reference": "RedoxPABeneficiary"},"relationship": [{"text": "Mother"}],"resourceType": "RelatedPerson"}},{"resource": {"id": "RedoxPAServiceClaimExample","use": "preauthorization","item": [{"sequence": 1,"extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService","valueReference": {"reference": "ServiceRequest/RedoxPAServiceRequestExample"}},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber","valueIdentifier": {"value": "23462346"}}],"productOrService": {"text": "Coronary angiography with right heart catheterization","coding": [{"code": "93456","system": "http://www.ama-assn.org/go/cpt"}]}}],"type": {"coding": [{"code": "professional","system": "http://terminology.hl7.org/CodeSystem/claim-type"}]},"status": "active","created": "2021-09-02T18:44:13.307Z","enterer": {"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"},"insurer": {"reference": "Organization/RedoxPAInsurerOrganizationExample"},"patient": {"reference": "Patient/RedoxPABeneficiaryExample"},"priority": {"coding": [{"code": "normal","system": "http://terminology.hl7.org/CodeSystem/processpriority"}]},"provider": {"reference": "Organization/RedoxPARequestorOrganizationExample"},"diagnosis": [{"sequence": 1,"diagnosisCodeableConcept": {"coding": 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In order to receive and process medication preauthorization requests, you must be able to support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that that processing looks like, but when you're ready to respond.
Make sure to include whether your connection's request is accepted, pending, or declined.
{"id": "RedoxClaimResponseBundleComprehensiveExample","type": "collection","entry": [{"resource": {"id": "RedoxPAClaimResponseExample","use": "preauthorization","item": [{"extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber","valueString": "REF456"},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate","valueDate": "2021-08-23"},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod","valuePeriod": {"end": "2021-09-23","start": "2021-08-23"}},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber","valueIdentifier": {"value": "23462346"}},{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail","extension": [{"url": "productOrServiceCode","valueCodeableConcept": {"text": "Right heart catheterization","coding": [{"code": "93451","system": "http://www.ama-assn.org/go/cpt"}]}},{"url": "quantity","valueQuantity": {"value": 1}},{"url": "unitPrice","valueMoney": {"value": 4966,"currency": "USD"}}]}],"adjudication": [{"category": {"coding": [{"code": "submitted","system": "http://terminology.hl7.org/CodeSystem/adjudication"}]},"extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction","extension": [{"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode","valueCodeableConcept": {"coding": [{"code": "A1","system": "https://codesystem.x12.org/005010/306","display": "Certified in total"}]}},{"url": "number","valueString": "AUTH1001"}]}]}],"itemSequence": 1}],"type": {"coding": [{"code": "professional","system": "http://terminology.hl7.org/CodeSystem/claim-type"}]},"status": "active","created": "2021-08-23T16:35:54.648Z","insurer": {"reference": "Organization/RedoxPAInsurerOrganizationExample"},"outcome": "complete","patient": {"reference": "Patient/RedoxPABeneficiaryExample"},"request": {"reference": "Claim/RedoxPAServiceClaimExample","identifier": {"type": {"coding": [{"code": "ClaimID"}]},"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"}},"requestor": {"reference": "Organization/RedoxPARequestorOrganizationExample"},"processNote": [{"text": "Covered under extended benefits"}],"resourceType": "ClaimResponse"}},{"resource": {"id": "RedoxPABeneficiaryExample","name": [{"given": ["Timothy","Paul"],"family": "Bixby"}],"gender": "male","birthDate": "2008-01-06","identifier": [{"value": "M23462346","system": "urn:redox:MRN"}],"resourceType": "Patient"}},{"resource": {"id": "RedoxPACoverageWithRelatedSubscriberExample","class": [{"type": {"coding": [{"code": "group","system": "http://terminology.hl7.org/CodeSystem/coverage-class"}]},"value": "GRP2245"}],"payor": [{"reference": "Organization/RedoxPAInsurerOrganizationExample"}],"status": "active","subscriber": {"reference": "RelatedPerson/RedoxPASubscriberExample"},"beneficiary": {"reference": "Patient/RedoxPABeneficiaryExample"},"resourceType": "Coverage","subscriberId": "M2346623"}},{"resource": {"id": "RedoxPARequestorOrganizationExample","name": "Good Health Clinics","active": true,"address": [{"city": "Madison","line": ["123 Main St."],"state": "WI","country": "USA","district": "Dane","postalCode": "53703"}],"resourceType": "Organization"}},{"resource": {"id": "RedoxPAInsurerOrganizationExample","name": "Aetna","active": true,"address": [{"city": "Lexington","line": ["PO Box 14080"],"state": "KY","country": "USA","district": "Fayette","postalCode": "40512-4079"}],"resourceType": "Organization"}},{"resource": {"id": "RedoxPAPractitionerRoleExamplePat","location": [{"display": "1st Street Family Clinic"}],"specialty": [{"coding": [{"code": "394579002","system": "http://snomed.info/sct","display": "Cardiology"}]}],"organization": {"reference": 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