You can use this API action to complete preauthorization, preapproval, or precertification before offering healthcare services or prescriptions. The intent of preauthorization is to confirm that the payer intends to pay for a high-cost service or prescription before it’s provided.
To find out if your request is approved, your connection would receive and respond to preauthorization requests.
You may see words like preauthorization and prior authorization used interchangeably. Similar to data exchange, the industry hasn’t standardized on one term for this process, so you may see different phrases, but they mean the same thing.
This API action may be a good fit for your organization if you perform any of these use cases:
- Confirm that the patient's insurance company will cover treatment.
- Check if a payer will pay for a prescription before writing a prescription.
- Get approval from the patient’s insurance company before:
- scheduling a patient's surgery;
- ordering durable medical equipment (e.g., braces, prosthetics) for a patient;
- ordering implantable medical devices (e.g., pacemaker) for a patient; or
- referring a patient to another level of care.
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 the Redox FHIR® API.
Your connection's system can receive claims with their own query-based API that can also exchange X12. Responses to preauthorization requests can be either synchronous or asynchronous, depending on your connection’s capabilities.
There are two primary kinds of preauthorization in healthcare, either for services or prescriptions.
For prescriptions, you may want to confirm that a payer will pay for a high-cost medication before a provider writes a prescription for a patient.
For services, you may need approval from a payer before recommending procedures or services. For example, recommending durable medical equipment, surgeries, or referring a patient to another level of care.
The goal of preauthorization is to reduce unnecessary spending in healthcare. It forces providers to exhaust all lower cost options before recommending high-cost options of equal value to the patient.
You must confirm that your connection can support this type of digital, automated workflow for preauthorizations. If your connection uses a manual workflow for preauthorizations (e.g., fax or online web portal), you won’t be able to use this API action. Your connection must support a digital workflow, whether it be X12, FHIR®, HL7v2, or a custom query-based API.
HIPAA uses the X12 data standard, which requires using Current Procedural Terminology (CPT) codes to designate outpatient services or procedures in the preauthorization request. For medication, equipment, or supplies for treatment, you must use Healthcare Common Procedure Coding System (HCPCS), Level II codes.
If you submit a preauthorization request, you can receive one of three responses: accepted, pending, or declined.
Typically, a payer returns a declined response if there’s not enough supporting information to make a decision. To avoid this, we recommend submitting X12 275 (an attachment with additional patient information) with your request to avoid delays in providing appropriate care. We support the X12 275 transaction with our Claim$attach operation. Learn more about X12 275 and refer to the Claim schema.
Does this API action seem like a good fit for your unique workflow? If so, let your Redox technical account manager know! You can start development by downloading the relevant resource schema (noted in the related action step below) and deciding which data elements you need. Then, use the Quickstart for Redox guide to dive right in.
If you're not engaged with our sales team yet, talk to a Redoxer to get started.
There are two types of preauthorization requests. Prescription requests allow you to receive approval for prescribed medication. Service requests allow you to receive approval for procedures, referrals, or medical equipment.
This table has notes about how to use parameters for this API action specifically, but it's not exhaustive. Refer to the Claim schema for more details.
Parameter | Required | Notes |
---|---|---|
entry | Y | This is where you include a MedicationRequest resource to indicate which kind of preauthorization request you're submitting. You must also include resources for Claim, Patient, Organization, Coverage, at a minimum. You may include other relevant resources to give context for your claim. |
Don't forget that the response may be either synchronous or asynchronous, depending on your connection's capabilities.
1{2"id": "RedoxMedicationClaimRequestBundleExample",3"Meta": {4"Logs": [5{6"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",7"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"8}9],10"Test": true,11"DataModel": "FHIR.Claim",12"EventType": "$submit-preauthorization",13"Destinations": [14{15"ID": "af394f14-b34a-464f-8d24-895f370af4c9",16"Name": "Redox EMR"17}18],19"EventDateTime": "2022-08-24T16:58:23.096Z"20},21"type": "collection",22"entry": [23{24"resource": {25"id": "RedoxPAMedicationClaimExample",26"use": "preauthorization",27"item": [28{29"sequence": 1,30"extension": [31{32"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",33"valueReference": {34"reference": "MedicationRequest/RedoxPAMedicationRequestExample"35}36}37],38"productOrService": {39"text": "Calan SR 240MG",40"coding": [41{42"code": "372754009",43"system": "http://snomed.info/sct"44}45]46}47}48],49"type": {50"coding": [51{52"code": "pharmacy",53"system": "http://terminology.hl7.org/CodeSystem/claim-type"54}55]56},57"status": "active",58"created": "2021-08-18T16:27:49.101Z",59"enterer": {60"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"61},62"insurer": {63"reference": "Organization/RedoxPAInsurerOrganizationExample"64},65"patient": {66"reference": "Patient/RedoxPABeneficiaryExample"67},68"priority": {69"coding": [70{71"code": "normal",72"system": "http://terminology.hl7.org/CodeSystem/processpriority"73}74]75},76"provider": {77"reference": "Organization/RedoxPARequestorOrganizationExample"78},79"diagnosis": [80{81"sequence": 1,82"diagnosisCodeableConcept": {83"coding": [84{85"code": "I10",86"system": "http://hl7.org/fhir/sid/icd-10-cm",87"display": "Essential (Primary) Hypertension"88}89]90}91}92],93"insurance": [94{95"focal": true,96"coverage": {97"reference": "Coverage/RedoxPACoverageExample"98},99"sequence": 1100}101],102"identifier": [103{104"type": {105"coding": [106{107"code": "ClaimID"108}109]110},111"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"112}113],114"resourceType": "Claim"115}116},117{118"resource": {119"id": "RedoxPAMedicationRequestExample",120"intent": "order",121"status": "active",122"subject": {123"reference": "Patient/RedoxPABeneficiaryExample"124},125"requester": {126"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"127},128"authoredOn": "2021-08-18T17:44:25.704Z",129"resourceType": "MedicationRequest",130"dispenseRequest": {131"quantity": {132"value": 60133},134"performer": {135"reference": "Organization/RedoxPAPharmacyOrganizationExample"136},137"expectedSupplyDuration": {138"code": "d",139"value": 30,140"system": "http://unitsofmeasure.org"141}142},143"dosageInstruction": [144{145"text": "Take 1 tablet two times a day until gone",146"doseAndRate": [147{148"doseQuantity": {149"code": "mg",150"value": 240,151"system": "http://unitsofmeasure.org"152}153}154]155}156],157"medicationCodeableConcept": {158"text": "Calan SR 240MG",159"coding": [160{161"code": "372754009",162"system": "http://snomed.info/sct"163}164]165}166}167},168{169"resource": {170"id": "RedoxPABeneficiaryExample",171"name": [172{173"given": [174"Timothy",175"Paul"176],177"family": "Bixby"178}179],180"gender": "male",181"birthDate": "2008-01-06",182"identifier": [183{184"value": "M23462346",185"system": "urn:redox:MRN"186}187],188"resourceType": "Patient"189}190},191{192"resource": {193"id": "RedoxPACoverageExample",194"class": [195{196"type": {197"coding": [198{199"code": "group",200"system": "http://terminology.hl7.org/CodeSystem/coverage-class"201}202]203},204"value": "GRP2245"205}206],207"payor": [208{209"reference": "Organization/RedoxPAInsurerOrganizationExample"210}211],212"status": "active",213"subscriber": {214"reference": "Patient/RedoxPABeneficiaryExample"215},216"beneficiary": {217"reference": "Patient/RedoxPABeneficiaryExample"218},219"resourceType": "Coverage",220"subscriberId": "T75644"221}222},223{224"resource": {225"id": "RedoxPARequestorOrganizationExample",226"name": "Good Health Clinics",227"active": true,228"address": [229{230"city": "Madison",231"line": [232"123 Main St."233],234"state": "WI",235"country": "USA",236"district": "Dane",237"postalCode": "53703"238}239],240"resourceType": "Organization"241}242},243{244"resource": {245"id": "RedoxPAInsurerOrganizationExample",246"name": "Aetna",247"active": true,248"address": [249{250"city": "Lexington",251"line": [252"PO Box 14080"253],254"state": "KY",255"country": "USA",256"district": "Fayette",257"postalCode": "40512-4079"258}259],260"resourceType": "Organization"261}262},263{264"resource": {265"id": "RedoxPAPharmacyOrganizationExample",266"name": "Rehome Pharmacy",267"active": true,268"address": [269{270"city": "Madison",271"line": [272"123 Fake St."273],274"state": "WI",275"country": "USA",276"district": "Dane",277"postalCode": "53703"278}279],280"resourceType": "Organization"281}282},283{284"resource": {285"id": "RedoxPAPractitionerRoleExamplePat",286"location": [287{288"display": "1st Street Family Clinic"289}290],291"specialty": [292{293"coding": [294{295"code": "394579002",296"system": "http://snomed.info/sct",297"display": "Cardiology"298}299]300}301],302"organization": {303"reference": "Organization/RedoxPARequestorOrganizationExample"304},305"practitioner": {306"reference": "Practitioner/RedoxPAPractitionerExamplePat"307},308"resourceType": "PractitionerRole"309}310},311{312"resource": {313"id": "RedoxPAPractitionerExamplePat",314"name": [315{316"given": [317"Pat"318],319"family": "Granite"320}321],322"address": [323{324"city": "Madison",325"line": [326"123 Main St."327],328"state": "WI",329"country": "USA",330"district": "Dane",331"postalCode": "53703"332}333],334"telecom": [335{336"value": "+16085551234"337}338],339"identifier": [340{341"value": "4356789876",342"system": "http://hl7.org/fhir/sid/us-npi"343}344],345"resourceType": "Practitioner"346}347}348],349"timestamp": "2021-08-18T16:18:43.649Z",350"identifier": {351"value": "urn:uuid:ef62bfe0-03fc-4509-9f9a-8fea04c1d025",352"system": "urn:ietf:rfc:3986"353},354"resourceType": "Bundle"355}
There are two types of preauthorization requests. Prescription requests allow you to receive approval for prescribed medication. Service requests allow you to receive approval for procedures, referrals, or medical equipment.
This table has notes about how to use parameters for this API action specifically, but it's not exhaustive. Refer to the Claim schema for more details.
Parameter | Required | Notes |
---|---|---|
entry | Y | This is where you include a ServiceRequest resource to indicate which kind of preauthorization request you're submitting. You must also include resources for Claim, Patient, Organization, Coverage, at a minimum. You may include other relevant resources to give context for your claim. |
Don't forget that the response may be either synchronous or asynchronous, depending on your connection's capabilities.
1{2"id": "RedoxMedicationClaimRequestBundleExample",3"Meta": {4"Logs": [5{6"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",7"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"8}9],10"Test": true,11"DataModel": "FHIR.Claim",12"EventType": "$submit-preauthorization",13"Destinations": [14{15"ID": "af394f14-b34a-464f-8d24-895f370af4c9",16"Name": "Redox EMR"17}18],19"EventDateTime": "2022-08-24T16:58:23.096Z"20},21"type": "collection",22"entry": [23{24"resource": {25"id": "RedoxPAMedicationClaimExample",26"use": "preauthorization",27"item": [28{29"sequence": 1,30"extension": [31{32"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",33"valueReference": {34"reference": "MedicationRequest/RedoxPAMedicationRequestExample"35}36}37],38"productOrService": {39"text": "Calan SR 240MG",40"coding": [41{42"code": "372754009",43"system": "http://snomed.info/sct"44}45]46}47}48],49"type": {50"coding": [51{52"code": "pharmacy",53"system": "http://terminology.hl7.org/CodeSystem/claim-type"54}55]56},57"status": "active",58"created": "2021-08-18T16:27:49.101Z",59"enterer": {60"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"61},62"insurer": {63"reference": "Organization/RedoxPAInsurerOrganizationExample"64},65"patient": {66"reference": "Patient/RedoxPABeneficiaryExample"67},68"priority": {69"coding": [70{71"code": "normal",72"system": "http://terminology.hl7.org/CodeSystem/processpriority"73}74]75},76"provider": {77"reference": "Organization/RedoxPARequestorOrganizationExample"78},79"diagnosis": [80{81"sequence": 1,82"diagnosisCodeableConcept": {83"coding": [84{85"code": "I10",86"system": "http://hl7.org/fhir/sid/icd-10-cm",87"display": "Essential (Primary) Hypertension"88}89]90}91}92],93"insurance": [94{95"focal": true,96"coverage": {97"reference": "Coverage/RedoxPACoverageExample"98},99"sequence": 1100}101],102"identifier": [103{104"type": {105"coding": [106{107"code": "ClaimID"108}109]110},111"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"112}113],114"resourceType": "Claim"115}116},117{118"resource": {119"id": "RedoxPAMedicationRequestExample",120"intent": "order",121"status": "active",122"subject": {123"reference": "Patient/RedoxPABeneficiaryExample"124},125"requester": {126"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"127},128"authoredOn": "2021-08-18T17:44:25.704Z",129"resourceType": "MedicationRequest",130"dispenseRequest": {131"quantity": {132"value": 60133},134"performer": {135"reference": "Organization/RedoxPAPharmacyOrganizationExample"136},137"expectedSupplyDuration": {138"code": "d",139"value": 30,140"system": "http://unitsofmeasure.org"141}142},143"dosageInstruction": [144{145"text": "Take 1 tablet two times a day until gone",146"doseAndRate": [147{148"doseQuantity": {149"code": "mg",150"value": 240,151"system": "http://unitsofmeasure.org"152}153}154]155}156],157"medicationCodeableConcept": {158"text": "Calan SR 240MG",159"coding": [160{161"code": "372754009",162"system": "http://snomed.info/sct"163}164]165}166}167},168{169"resource": {170"id": "RedoxPABeneficiaryExample",171"name": [172{173"given": [174"Timothy",175"Paul"176],177"family": "Bixby"178}179],180"gender": "male",181"birthDate": "2008-01-06",182"identifier": [183{184"value": "M23462346",185"system": "urn:redox:MRN"186}187],188"resourceType": "Patient"189}190},191{192"resource": {193"id": "RedoxPACoverageExample",194"class": [195{196"type": {197"coding": [198{199"code": "group",200"system": "http://terminology.hl7.org/CodeSystem/coverage-class"201}202]203},204"value": "GRP2245"205}206],207"payor": [208{209"reference": "Organization/RedoxPAInsurerOrganizationExample"210}211],212"status": "active",213"subscriber": {214"reference": "Patient/RedoxPABeneficiaryExample"215},216"beneficiary": {217"reference": "Patient/RedoxPABeneficiaryExample"218},219"resourceType": "Coverage",220"subscriberId": "T75644"221}222},223{224"resource": {225"id": "RedoxPARequestorOrganizationExample",226"name": "Good Health Clinics",227"active": true,228"address": [229{230"city": "Madison",231"line": [232"123 Main St."233],234"state": "WI",235"country": "USA",236"district": "Dane",237"postalCode": "53703"238}239],240"resourceType": "Organization"241}242},243{244"resource": {245"id": "RedoxPAInsurerOrganizationExample",246"name": "Aetna",247"active": true,248"address": [249{250"city": "Lexington",251"line": [252"PO Box 14080"253],254"state": "KY",255"country": "USA",256"district": "Fayette",257"postalCode": "40512-4079"258}259],260"resourceType": "Organization"261}262},263{264"resource": {265"id": "RedoxPAPharmacyOrganizationExample",266"name": "Rehome Pharmacy",267"active": true,268"address": [269{270"city": "Madison",271"line": [272"123 Fake St."273],274"state": "WI",275"country": "USA",276"district": "Dane",277"postalCode": "53703"278}279],280"resourceType": "Organization"281}282},283{284"resource": {285"id": "RedoxPAPractitionerRoleExamplePat",286"location": [287{288"display": "1st Street Family Clinic"289}290],291"specialty": [292{293"coding": [294{295"code": "394579002",296"system": "http://snomed.info/sct",297"display": "Cardiology"298}299]300}301],302"organization": {303"reference": "Organization/RedoxPARequestorOrganizationExample"304},305"practitioner": {306"reference": "Practitioner/RedoxPAPractitionerExamplePat"307},308"resourceType": "PractitionerRole"309}310},311{312"resource": {313"id": "RedoxPAPractitionerExamplePat",314"name": [315{316"given": [317"Pat"318],319"family": "Granite"320}321],322"address": [323{324"city": "Madison",325"line": [326"123 Main St."327],328"state": "WI",329"country": "USA",330"district": "Dane",331"postalCode": "53703"332}333],334"telecom": [335{336"value": "+16085551234"337}338],339"identifier": [340{341"value": "4356789876",342"system": "http://hl7.org/fhir/sid/us-npi"343}344],345"resourceType": "Practitioner"346}347}348],349"timestamp": "2021-08-18T16:18:43.649Z",350"identifier": {351"value": "urn:uuid:ef62bfe0-03fc-4509-9f9a-8fea04c1d025",352"system": "urn:ietf:rfc:3986"353},354"resourceType": "Bundle"355}
This is an optional but highly recommended step if you want to avoid getting a declined response. Completing this step allows you to provide supporting information for your claim. Please do your homework by submitting all supporting evidence to make sure your claim is processed as seamlessly as possible.
Refer to the Claim schema for more details.
1curl 'https://api.redoxengine.com/fhir/R4/redox-fhir-sandbox/Development/Claim/$attach' \2--request POST \3--header 'Authorization: Bearer ${API_TOKEN}' \4--header 'Content-Type: application/json' \5--data '{6"id": "RedoxClaimAttachBundleExample",7"Meta": {8"Logs": [9{10"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",11"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"12}13],14"Test": true,15"DataModel": "FHIR.Claim",16"EventType": "$attach",17"Destinations": [18{19"ID": "af394f14-b34a-464f-8d24-895f370af4c9",20"Name": "Redox EMR"21}22],23"EventDateTime": "2022-08-24T17:30:25.256Z"24},25"meta": {26"extension": [27{28"url": "https://fhir.redoxengine.com/StructureDefinition/example-sort-order",29"valueInteger": 130}31]32},33"type": "collection",34"entry": [35{36"resource": {37"id": "RedoxPADocumentReferenceExample",38"status": "current",39"content": [40{41"attachment": {42"data": "SW1hZ2luZSB0aGlzIGlzIGEgYmluYXJ5IFBERiBkb2N1bWVudA==",43"title": "Timothy Chart.pdf",44"contentType": "application/pdf"45}46}47],48"context": {49"related": [50{51"identifier": {52"type": {53"coding": [54{55"code": "ClaimID"56}57]58},59"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"60}61}62]63},64"resourceType": "DocumentReference"65}66}67],68"timestamp": "2022-01-14T19:46:21.374Z",69"resourceType": "Bundle"70}'
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