You can use this API action if your organization is a healthcare organization or health tech vendor that performs preauthorization, preapproval, or precertification before offering healthcare services or prescriptions. The intent of the preauthorization process is to confirm that the payer intends to pay for a high cost service or prescription before it’s provided.
You can typically use this API action for:
- confirming a provider’s treatment will be covered by the patient’s insurance company;
- checking if a payer intends to pay for a prescription prior to prescribing; or
- getting approval from the patient’s insurance company before
- scheduling a patient surgery
- ordering durable medical equipment (e.g., brace, prosthetics) for a patient
- ordering implantable medical devices (e.g., pacemaker) for a patient
- 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.
To find out if your request is approved, your connection receives and responds to preauthorization requests.
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 different types of preauthorization requests: one for prescriptions and one for services. Prescription requests allows you to receive approval for prescribed medication while 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 resource schema for more details.
Parameter | Required | Notes |
|---|---|---|
entry | Y | This is where you include either a MedicationRequest resource to designate which kind of preauthorization request you're submitting. You must also include resources for Claim, Patient, Organization, Coverage, at a minimum. You may find include other relevant resources to give context for your claim. |
And don't forget that the response may be either synchronous or asynchronous, depending on your connection's capabilities.
There are two different types of preauthorization requests: one for prescriptions and one for services. Prescription requests allows you to receive approval for prescribed medication while 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 resource schema for more details.
Parameter | Required | Notes |
|---|---|---|
entry | Y | This is where you include a ServiceRequest resource to designate which kind of preauthorization request you're submitting. You must also include resources for Claim, Patient, Organization, Coverage, at a minimum. You may find include other relevant resources to give context for your claim. |
And don't forget that the response may be either synchronous or asynchronous, depending on your connection's capabilities.
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. So please do your homework by submitting all supporting evidence to make sure your claim is processed as seamlessly as possible.
Refer to the resource schema for more details.