Receive and respond to preauthorization requests

You can use this API action to process and respond to preauthorization requests. To kick off your workflow, your connection must submit a preauthorization request.

Use cases

This API action may be a good fit for your organization if you perform any of these use cases:

  • Approve or decline preauthorization requests.
  • Streamline or digitize your process for receiving preauthorization requests.

Check out our case study for more details about the problems you can solve with this API action. 

Supported systems

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.

Things you need to know

Action steps

Respond to a medication preauthorization request

This step requires that you support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that processing looks like when you're ready to respond. Refer to these schemas for more details:

In the response, you must include whether your connection's request is accepted, pending, or declined.

ClaimResponse/$respond
{
"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": [
{
"code": "I42.9",
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"display": "Cardiomyopathy, unspecified"
}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/RedoxPACoverageExample"
},
"sequence": 1
}
],
"identifier": [
{
"type": {
"coding": [
{
"code": "ClaimID"
}
]
},
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
}
],
"resourceType": "Claim",
"supportingInfo": [
{
"category": {
"coding": [
{
"code": "additionalInformation",
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
"display": "Send additional paperwork or supporting information is sent for the request."
}
]
},
"sequence": 1,
"valueReference": {
"reference": "DocumentReference/RedoxPADocumentReferenceExample"
}
},
{
"category": {
"coding": [
{
"code": "freeFormMessage",
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
"display": "Written Confirmation."
}
]
},
"sequence": 2,
"valueString": "1"
}
]
}
}
],
"timestamp": "2021-10-21T19:09:02.452Z",
"identifier": {
"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",
"system": "urn:ietf:rfc:3986"
},
"resourceType": "Bundle"
}

Respond to a service preauthorization request

This action step requires that you support receiving Claim$submit-preauthorization and Claim$attach from your connection. You can decide what that processing looks like when you're ready to respond. Refer to these schemas for more details:

In the response, you must include whether your connection's request is accepted, pending, or declined.

ClaimResponse/$respond
{
"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": [
{
"code": "I42.9",
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"display": "Cardiomyopathy, unspecified"
}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/RedoxPACoverageExample"
},
"sequence": 1
}
],
"identifier": [
{
"type": {
"coding": [
{
"code": "ClaimID"
}
]
},
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
}
],
"resourceType": "Claim",
"supportingInfo": [
{
"category": {
"coding": [
{
"code": "additionalInformation",
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
"display": "Send additional paperwork or supporting information is sent for the request."
}
]
},
"sequence": 1,
"valueReference": {
"reference": "DocumentReference/RedoxPADocumentReferenceExample"
}
},
{
"category": {
"coding": [
{
"code": "freeFormMessage",
"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",
"display": "Written Confirmation."
}
]
},
"sequence": 2,
"valueString": "1"
}
]
}
}
],
"timestamp": "2021-10-21T19:09:02.452Z",
"identifier": {
"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",
"system": "urn:ietf:rfc:3986"
},
"resourceType": "Bundle"
}