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.
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.
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.
We recommend that you review the Claim$submit-preauthorization schema for two reasons.
First, you should make sure you can support all the required data points to receive a preauthorization request.
Second, you should confirm that it contains all the data your organization requires to process and approve a preauthorization request.
HIPAA uses the X12 data standard, so your connection must use Current Procedural Terminology (CPT) codes to designate outpatient services or procedures in the preauthorization request. For medication, equipment, or supplies for treatment, your connection must use Healthcare Common Procedure Coding System (HCPCS), Level II codes. Make sure that you can support each of these code sets.
You receive preauthorization data within the FHIR® Claim resource. While we generally support filters to reduce unwanted messages, we don’t support applying comprehensive business logic or rules to incoming Claim data.
Does this API action seem like a good fit for your unique workflow? If so, let your Redox technical account manager know! You can start development by downloading the relevant resource schema (noted in the related action step below) and deciding which data elements you need. Then, use our Redox Nexus Quickstart guide to dive right in.
If you're not engaged with our sales team yet, talk to a Redoxer to get started.
This step requires that you support receiving Claim$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.
1{2"id": "RedoxClaimResponseBundleComprehensiveExample",3"type": "collection",4"entry": [5{6"resource": {7"id": "RedoxPAClaimResponseExample",8"use": "preauthorization",9"item": [10{11"extension": [12{13"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",14"valueString": "REF456"15},16{17"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",18"valueDate": "2021-08-23"19},20{21"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",22"valuePeriod": {23"end": "2021-09-23",24"start": "2021-08-23"25}26},27{28"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",29"valueIdentifier": {30"value": "23462346"31}32},33{34"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail",35"extension": [36{37"url": "productOrServiceCode",38"valueCodeableConcept": {39"text": "Right heart catheterization",40"coding": [41{42"code": "93451",43"system": "http://www.ama-assn.org/go/cpt"44}45]46}47},48{49"url": "quantity",50"valueQuantity": {51"value": 152}53},54{55"url": "unitPrice",56"valueMoney": {57"value": 4966,58"currency": "USD"59}60}61]62}63],64"adjudication": [65{66"category": {67"coding": [68{69"code": "submitted",70"system": "http://terminology.hl7.org/CodeSystem/adjudication"71}72]73},74"extension": [75{76"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",77"extension": [78{79"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",80"valueCodeableConcept": {81"coding": [82{83"code": "A1",84"system": "https://codesystem.x12.org/005010/306",85"display": "Certified in total"86}87]88}89},90{91"url": "number",92"valueString": "AUTH1001"93}94]95}96]97}98],99"itemSequence": 1100}101],102"type": {103"coding": [104{105"code": "professional",106"system": "http://terminology.hl7.org/CodeSystem/claim-type"107}108]109},110"status": "active",111"created": "2021-08-23T16:35:54.648Z",112"insurer": {113"reference": "Organization/RedoxPAInsurerOrganizationExample"114},115"outcome": "complete",116"patient": {117"reference": "Patient/RedoxPABeneficiaryExample"118},119"request": {120"reference": "Claim/RedoxPAServiceClaimExample",121"identifier": {122"type": {123"coding": [124{125"code": "ClaimID"126}127]128},129"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"130}131},132"requestor": {133"reference": "Organization/RedoxPARequestorOrganizationExample"134},135"processNote": [136{137"text": "Covered under extended benefits"138}139],140"resourceType": "ClaimResponse"141}142},143{144"resource": {145"id": "RedoxPABeneficiaryExample",146"name": [147{148"given": [149"Timothy",150"Paul"151],152"family": "Bixby"153}154],155"gender": "male",156"birthDate": "2008-01-06",157"identifier": [158{159"value": "M23462346",160"system": "urn:redox:MRN"161}162],163"resourceType": "Patient"164}165},166{167"resource": {168"id": "RedoxPACoverageWithRelatedSubscriberExample",169"class": [170{171"type": {172"coding": [173{174"code": "group",175"system": "http://terminology.hl7.org/CodeSystem/coverage-class"176}177]178},179"value": "GRP2245"180}181],182"payor": [183{184"reference": "Organization/RedoxPAInsurerOrganizationExample"185}186],187"status": "active",188"subscriber": {189"reference": "RelatedPerson/RedoxPASubscriberExample"190},191"beneficiary": {192"reference": "Patient/RedoxPABeneficiaryExample"193},194"resourceType": "Coverage",195"subscriberId": "M2346623"196}197},198{199"resource": {200"id": "RedoxPARequestorOrganizationExample",201"name": "Good Health Clinics",202"active": true,203"address": [204{205"city": "Madison",206"line": [207"123 Main St."208],209"state": "WI",210"country": "USA",211"district": "Dane",212"postalCode": "53703"213}214],215"resourceType": "Organization"216}217},218{219"resource": {220"id": "RedoxPAInsurerOrganizationExample",221"name": "Aetna",222"active": true,223"address": [224{225"city": "Lexington",226"line": [227"PO Box 14080"228],229"state": "KY",230"country": "USA",231"district": "Fayette",232"postalCode": "40512-4079"233}234],235"resourceType": "Organization"236}237},238{239"resource": {240"id": "RedoxPAPractitionerRoleExamplePat",241"location": [242{243"display": "1st Street Family Clinic"244}245],246"specialty": [247{248"coding": [249{250"code": "394579002",251"system": "http://snomed.info/sct",252"display": "Cardiology"253}254]255}256],257"organization": {258"reference": "Organization/RedoxPARequestorOrganizationExample"259},260"practitioner": {261"reference": "Practitioner/RedoxPAPractitionerExamplePat"262},263"resourceType": "PractitionerRole"264}265},266{267"resource": {268"id": "RedoxPAPractitionerExamplePat",269"name": [270{271"given": [272"Pat"273],274"family": "Granite"275}276],277"address": [278{279"city": "Madison",280"line": [281"123 Main St."282],283"state": "WI",284"country": "USA",285"district": "Dane",286"postalCode": "53703"287}288],289"telecom": [290{291"value": "+16085551234"292}293],294"identifier": [295{296"value": "4356789876",297"system": "http://hl7.org/fhir/sid/us-npi"298}299],300"resourceType": "Practitioner"301}302},303{304"resource": {305"id": "RedoxPASubscriberExample",306"name": [307{308"given": [309"Barbara"310],311"family": "Bixby"312}313],314"patient": {315"reference": "RedoxPABeneficiary"316},317"relationship": [318{319"text": "Mother"320}321],322"resourceType": "RelatedPerson"323}324},325{326"resource": {327"id": "RedoxPAServiceClaimExample",328"use": "preauthorization",329"item": [330{331"sequence": 1,332"extension": [333{334"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",335"valueReference": {336"reference": "ServiceRequest/RedoxPAServiceRequestExample"337}338},339{340"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",341"valueIdentifier": {342"value": "23462346"343}344}345],346"productOrService": {347"text": "Coronary angiography with right heart catheterization",348"coding": [349{350"code": "93456",351"system": "http://www.ama-assn.org/go/cpt"352}353]354}355}356],357"type": {358"coding": [359{360"code": "professional",361"system": "http://terminology.hl7.org/CodeSystem/claim-type"362}363]364},365"status": "active",366"created": "2021-09-02T18:44:13.307Z",367"enterer": {368"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"369},370"insurer": {371"reference": "Organization/RedoxPAInsurerOrganizationExample"372},373"patient": {374"reference": "Patient/RedoxPABeneficiaryExample"375},376"priority": {377"coding": [378{379"code": "normal",380"system": "http://terminology.hl7.org/CodeSystem/processpriority"381}382]383},384"provider": {385"reference": "Organization/RedoxPARequestorOrganizationExample"386},387"diagnosis": [388{389"sequence": 1,390"diagnosisCodeableConcept": {391"coding": [392{393"code": "I42.9",394"system": "http://hl7.org/fhir/sid/icd-10-cm",395"display": "Cardiomyopathy, unspecified"396}397]398}399}400],401"insurance": [402{403"focal": true,404"coverage": {405"reference": "Coverage/RedoxPACoverageExample"406},407"sequence": 1408}409],410"identifier": [411{412"type": {413"coding": [414{415"code": "ClaimID"416}417]418},419"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"420}421],422"resourceType": "Claim",423"supportingInfo": [424{425"category": {426"coding": [427{428"code": "additionalInformation",429"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",430"display": "Send additional paperwork or supporting information is sent for the request."431}432]433},434"sequence": 1,435"valueReference": {436"reference": "DocumentReference/RedoxPADocumentReferenceExample"437}438},439{440"category": {441"coding": [442{443"code": "freeFormMessage",444"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",445"display": "Written Confirmation."446}447]448},449"sequence": 2,450"valueString": "1"451}452]453}454}455],456"timestamp": "2021-10-21T19:09:02.452Z",457"identifier": {458"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",459"system": "urn:ietf:rfc:3986"460},461"resourceType": "Bundle"462}
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.
1{2"id": "RedoxClaimResponseBundleComprehensiveExample",3"type": "collection",4"entry": [5{6"resource": {7"id": "RedoxPAClaimResponseExample",8"use": "preauthorization",9"item": [10{11"extension": [12{13"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber",14"valueString": "REF456"15},16{17"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate",18"valueDate": "2021-08-23"19},20{21"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod",22"valuePeriod": {23"end": "2021-09-23",24"start": "2021-08-23"25}26},27{28"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",29"valueIdentifier": {30"value": "23462346"31}32},33{34"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail",35"extension": [36{37"url": "productOrServiceCode",38"valueCodeableConcept": {39"text": "Right heart catheterization",40"coding": [41{42"code": "93451",43"system": "http://www.ama-assn.org/go/cpt"44}45]46}47},48{49"url": "quantity",50"valueQuantity": {51"value": 152}53},54{55"url": "unitPrice",56"valueMoney": {57"value": 4966,58"currency": "USD"59}60}61]62}63],64"adjudication": [65{66"category": {67"coding": [68{69"code": "submitted",70"system": "http://terminology.hl7.org/CodeSystem/adjudication"71}72]73},74"extension": [75{76"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction",77"extension": [78{79"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode",80"valueCodeableConcept": {81"coding": [82{83"code": "A1",84"system": "https://codesystem.x12.org/005010/306",85"display": "Certified in total"86}87]88}89},90{91"url": "number",92"valueString": "AUTH1001"93}94]95}96]97}98],99"itemSequence": 1100}101],102"type": {103"coding": [104{105"code": "professional",106"system": "http://terminology.hl7.org/CodeSystem/claim-type"107}108]109},110"status": "active",111"created": "2021-08-23T16:35:54.648Z",112"insurer": {113"reference": "Organization/RedoxPAInsurerOrganizationExample"114},115"outcome": "complete",116"patient": {117"reference": "Patient/RedoxPABeneficiaryExample"118},119"request": {120"reference": "Claim/RedoxPAServiceClaimExample",121"identifier": {122"type": {123"coding": [124{125"code": "ClaimID"126}127]128},129"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"130}131},132"requestor": {133"reference": "Organization/RedoxPARequestorOrganizationExample"134},135"processNote": [136{137"text": "Covered under extended benefits"138}139],140"resourceType": "ClaimResponse"141}142},143{144"resource": {145"id": "RedoxPABeneficiaryExample",146"name": [147{148"given": [149"Timothy",150"Paul"151],152"family": "Bixby"153}154],155"gender": "male",156"birthDate": "2008-01-06",157"identifier": [158{159"value": "M23462346",160"system": "urn:redox:MRN"161}162],163"resourceType": "Patient"164}165},166{167"resource": {168"id": "RedoxPACoverageWithRelatedSubscriberExample",169"class": [170{171"type": {172"coding": [173{174"code": "group",175"system": "http://terminology.hl7.org/CodeSystem/coverage-class"176}177]178},179"value": "GRP2245"180}181],182"payor": [183{184"reference": "Organization/RedoxPAInsurerOrganizationExample"185}186],187"status": "active",188"subscriber": {189"reference": "RelatedPerson/RedoxPASubscriberExample"190},191"beneficiary": {192"reference": "Patient/RedoxPABeneficiaryExample"193},194"resourceType": "Coverage",195"subscriberId": "M2346623"196}197},198{199"resource": {200"id": "RedoxPARequestorOrganizationExample",201"name": "Good Health Clinics",202"active": true,203"address": [204{205"city": "Madison",206"line": [207"123 Main St."208],209"state": "WI",210"country": "USA",211"district": "Dane",212"postalCode": "53703"213}214],215"resourceType": "Organization"216}217},218{219"resource": {220"id": "RedoxPAInsurerOrganizationExample",221"name": "Aetna",222"active": true,223"address": [224{225"city": "Lexington",226"line": [227"PO Box 14080"228],229"state": "KY",230"country": "USA",231"district": "Fayette",232"postalCode": "40512-4079"233}234],235"resourceType": "Organization"236}237},238{239"resource": {240"id": "RedoxPAPractitionerRoleExamplePat",241"location": [242{243"display": "1st Street Family Clinic"244}245],246"specialty": [247{248"coding": [249{250"code": "394579002",251"system": "http://snomed.info/sct",252"display": "Cardiology"253}254]255}256],257"organization": {258"reference": "Organization/RedoxPARequestorOrganizationExample"259},260"practitioner": {261"reference": "Practitioner/RedoxPAPractitionerExamplePat"262},263"resourceType": "PractitionerRole"264}265},266{267"resource": {268"id": "RedoxPAPractitionerExamplePat",269"name": [270{271"given": [272"Pat"273],274"family": "Granite"275}276],277"address": [278{279"city": "Madison",280"line": [281"123 Main St."282],283"state": "WI",284"country": "USA",285"district": "Dane",286"postalCode": "53703"287}288],289"telecom": [290{291"value": "+16085551234"292}293],294"identifier": [295{296"value": "4356789876",297"system": "http://hl7.org/fhir/sid/us-npi"298}299],300"resourceType": "Practitioner"301}302},303{304"resource": {305"id": "RedoxPASubscriberExample",306"name": [307{308"given": [309"Barbara"310],311"family": "Bixby"312}313],314"patient": {315"reference": "RedoxPABeneficiary"316},317"relationship": [318{319"text": "Mother"320}321],322"resourceType": "RelatedPerson"323}324},325{326"resource": {327"id": "RedoxPAServiceClaimExample",328"use": "preauthorization",329"item": [330{331"sequence": 1,332"extension": [333{334"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",335"valueReference": {336"reference": "ServiceRequest/RedoxPAServiceRequestExample"337}338},339{340"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber",341"valueIdentifier": {342"value": "23462346"343}344}345],346"productOrService": {347"text": "Coronary angiography with right heart catheterization",348"coding": [349{350"code": "93456",351"system": "http://www.ama-assn.org/go/cpt"352}353]354}355}356],357"type": {358"coding": [359{360"code": "professional",361"system": "http://terminology.hl7.org/CodeSystem/claim-type"362}363]364},365"status": "active",366"created": "2021-09-02T18:44:13.307Z",367"enterer": {368"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"369},370"insurer": {371"reference": "Organization/RedoxPAInsurerOrganizationExample"372},373"patient": {374"reference": "Patient/RedoxPABeneficiaryExample"375},376"priority": {377"coding": [378{379"code": "normal",380"system": "http://terminology.hl7.org/CodeSystem/processpriority"381}382]383},384"provider": {385"reference": "Organization/RedoxPARequestorOrganizationExample"386},387"diagnosis": [388{389"sequence": 1,390"diagnosisCodeableConcept": {391"coding": [392{393"code": "I42.9",394"system": "http://hl7.org/fhir/sid/icd-10-cm",395"display": "Cardiomyopathy, unspecified"396}397]398}399}400],401"insurance": [402{403"focal": true,404"coverage": {405"reference": "Coverage/RedoxPACoverageExample"406},407"sequence": 1408}409],410"identifier": [411{412"type": {413"coding": [414{415"code": "ClaimID"416}417]418},419"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"420}421],422"resourceType": "Claim",423"supportingInfo": [424{425"category": {426"coding": [427{428"code": "additionalInformation",429"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",430"display": "Send additional paperwork or supporting information is sent for the request."431}432]433},434"sequence": 1,435"valueReference": {436"reference": "DocumentReference/RedoxPADocumentReferenceExample"437}438},439{440"category": {441"coding": [442{443"code": "freeFormMessage",444"system": "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType",445"display": "Written Confirmation."446}447]448},449"sequence": 2,450"valueString": "1"451}452]453}454}455],456"timestamp": "2021-10-21T19:09:02.452Z",457"identifier": {458"value": "urn:uuid:59f129cf-2eca-4965-88f2-452558af1934",459"system": "urn:ietf:rfc:3986"460},461"resourceType": "Bundle"462}
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