Submit preauthorization

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.

Use cases

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.

Supported systems

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.

Things you need to know

Action steps

Submit a medication preauthorization request

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 resource 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.

Claim/$submit-preauthorization
{
"id": "RedoxMedicationClaimRequestBundleExample",
"Meta": {
"Logs": [
{
"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",
"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"
}
],
"Test": true,
"DataModel": "FHIR.Claim",
"EventType": "$submit-preauthorization",
"Destinations": [
{
"ID": "af394f14-b34a-464f-8d24-895f370af4c9",
"Name": "Redox EMR"
}
],
"EventDateTime": "2022-08-24T16:58:23.096Z"
},
"type": "collection",
"entry": [
{
"resource": {
"id": "RedoxPAMedicationClaimExample",
"use": "preauthorization",
"item": [
{
"sequence": 1,
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference": {
"reference": "MedicationRequest/RedoxPAMedicationRequestExample"
}
}
],
"productOrService": {
"text": "Calan SR 240MG",
"coding": [
{
"code": "372754009",
"system": "http://snomed.info/sct"
}
]
}
}
],
"type": {
"coding": [
{
"code": "pharmacy",
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
}
]
},
"status": "active",
"created": "2021-08-18T16:27:49.101Z",
"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": "I10",
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"display": "Essential (Primary) Hypertension"
}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/RedoxPACoverageExample"
},
"sequence": 1
}
],
"identifier": [
{
"type": {
"coding": [
{
"code": "ClaimID"
}
]
},
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
}
],
"resourceType": "Claim"
}
},
{
"resource": {
"id": "RedoxPAMedicationRequestExample",
"intent": "order",
"status": "active",
"subject": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"requester": {
"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
},
"authoredOn": "2021-08-18T17:44:25.704Z",
"resourceType": "MedicationRequest",
"dispenseRequest": {
"quantity": {
"value": 60
},
"performer": {
"reference": "Organization/RedoxPAPharmacyOrganizationExample"
},
"expectedSupplyDuration": {
"code": "d",
"value": 30,
"system": "http://unitsofmeasure.org"
}
},
"dosageInstruction": [
{
"text": "Take 1 tablet two times a day until gone",
"doseAndRate": [
{
"doseQuantity": {
"code": "mg",
"value": 240,
"system": "http://unitsofmeasure.org"
}
}
]
}
],
"medicationCodeableConcept": {
"text": "Calan SR 240MG",
"coding": [
{
"code": "372754009",
"system": "http://snomed.info/sct"
}
]
}
}
},
{
"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": "RedoxPACoverageExample",
"class": [
{
"type": {
"coding": [
{
"code": "group",
"system": "http://terminology.hl7.org/CodeSystem/coverage-class"
}
]
},
"value": "GRP2245"
}
],
"payor": [
{
"reference": "Organization/RedoxPAInsurerOrganizationExample"
}
],
"status": "active",
"subscriber": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"beneficiary": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"resourceType": "Coverage",
"subscriberId": "T75644"
}
},
{
"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": "RedoxPAPharmacyOrganizationExample",
"name": "Rehome Pharmacy",
"active": true,
"address": [
{
"city": "Madison",
"line": [
"123 Fake St."
],
"state": "WI",
"country": "USA",
"district": "Dane",
"postalCode": "53703"
}
],
"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"
}
}
],
"timestamp": "2021-08-18T16:18:43.649Z",
"identifier": {
"value": "urn:uuid:ef62bfe0-03fc-4509-9f9a-8fea04c1d025",
"system": "urn:ietf:rfc:3986"
},
"resourceType": "Bundle"
}

Submit a service preauthorization request

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 resource 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.

Claim/$submit-preauthorization
{
"id": "RedoxMedicationClaimRequestBundleExample",
"Meta": {
"Logs": [
{
"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",
"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"
}
],
"Test": true,
"DataModel": "FHIR.Claim",
"EventType": "$submit-preauthorization",
"Destinations": [
{
"ID": "af394f14-b34a-464f-8d24-895f370af4c9",
"Name": "Redox EMR"
}
],
"EventDateTime": "2022-08-24T16:58:23.096Z"
},
"type": "collection",
"entry": [
{
"resource": {
"id": "RedoxPAMedicationClaimExample",
"use": "preauthorization",
"item": [
{
"sequence": 1,
"extension": [
{
"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
"valueReference": {
"reference": "MedicationRequest/RedoxPAMedicationRequestExample"
}
}
],
"productOrService": {
"text": "Calan SR 240MG",
"coding": [
{
"code": "372754009",
"system": "http://snomed.info/sct"
}
]
}
}
],
"type": {
"coding": [
{
"code": "pharmacy",
"system": "http://terminology.hl7.org/CodeSystem/claim-type"
}
]
},
"status": "active",
"created": "2021-08-18T16:27:49.101Z",
"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": "I10",
"system": "http://hl7.org/fhir/sid/icd-10-cm",
"display": "Essential (Primary) Hypertension"
}
]
}
}
],
"insurance": [
{
"focal": true,
"coverage": {
"reference": "Coverage/RedoxPACoverageExample"
},
"sequence": 1
}
],
"identifier": [
{
"type": {
"coding": [
{
"code": "ClaimID"
}
]
},
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
}
],
"resourceType": "Claim"
}
},
{
"resource": {
"id": "RedoxPAMedicationRequestExample",
"intent": "order",
"status": "active",
"subject": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"requester": {
"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
},
"authoredOn": "2021-08-18T17:44:25.704Z",
"resourceType": "MedicationRequest",
"dispenseRequest": {
"quantity": {
"value": 60
},
"performer": {
"reference": "Organization/RedoxPAPharmacyOrganizationExample"
},
"expectedSupplyDuration": {
"code": "d",
"value": 30,
"system": "http://unitsofmeasure.org"
}
},
"dosageInstruction": [
{
"text": "Take 1 tablet two times a day until gone",
"doseAndRate": [
{
"doseQuantity": {
"code": "mg",
"value": 240,
"system": "http://unitsofmeasure.org"
}
}
]
}
],
"medicationCodeableConcept": {
"text": "Calan SR 240MG",
"coding": [
{
"code": "372754009",
"system": "http://snomed.info/sct"
}
]
}
}
},
{
"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": "RedoxPACoverageExample",
"class": [
{
"type": {
"coding": [
{
"code": "group",
"system": "http://terminology.hl7.org/CodeSystem/coverage-class"
}
]
},
"value": "GRP2245"
}
],
"payor": [
{
"reference": "Organization/RedoxPAInsurerOrganizationExample"
}
],
"status": "active",
"subscriber": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"beneficiary": {
"reference": "Patient/RedoxPABeneficiaryExample"
},
"resourceType": "Coverage",
"subscriberId": "T75644"
}
},
{
"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": "RedoxPAPharmacyOrganizationExample",
"name": "Rehome Pharmacy",
"active": true,
"address": [
{
"city": "Madison",
"line": [
"123 Fake St."
],
"state": "WI",
"country": "USA",
"district": "Dane",
"postalCode": "53703"
}
],
"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"
}
}
],
"timestamp": "2021-08-18T16:18:43.649Z",
"identifier": {
"value": "urn:uuid:ef62bfe0-03fc-4509-9f9a-8fea04c1d025",
"system": "urn:ietf:rfc:3986"
},
"resourceType": "Bundle"
}

Attach supporting documentation

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 resource schema for more details.

Claim/$attach
curl 'https://api.redoxengine.com/fhir/R4/redox-fhir-sandbox/Development/Claim/$attach' \
--request POST \
--header 'Authorization: Bearer ${API_TOKEN}' \
--header 'Content-Type: application/json' \
--data '{
"id": "RedoxClaimAttachBundleExample",
"Meta": {
"Logs": [
{
"ID": "d9f5d293-7110-461e-a875-3beb089e79f3",
"AttemptID": "925d1617-2fe0-468c-a14c-f8c04b572c54"
}
],
"Test": true,
"DataModel": "FHIR.Claim",
"EventType": "$attach",
"Destinations": [
{
"ID": "af394f14-b34a-464f-8d24-895f370af4c9",
"Name": "Redox EMR"
}
],
"EventDateTime": "2022-08-24T17:30:25.256Z"
},
"meta": {
"extension": [
{
"url": "https://fhir.redoxengine.com/StructureDefinition/example-sort-order",
"valueInteger": 1
}
]
},
"type": "collection",
"entry": [
{
"resource": {
"id": "RedoxPADocumentReferenceExample",
"status": "current",
"content": [
{
"attachment": {
"data": "SW1hZ2luZSB0aGlzIGlzIGEgYmluYXJ5IFBERiBkb2N1bWVudA==",
"title": "Timothy Chart.pdf",
"contentType": "application/pdf"
}
}
],
"context": {
"related": [
{
"identifier": {
"type": {
"coding": [
{
"code": "ClaimID"
}
]
},
"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
}
}
]
},
"resourceType": "DocumentReference"
}
}
],
"timestamp": "2022-01-14T19:46:21.374Z",
"resourceType": "Bundle"
}'