PAS: the request and the response

Send the request, read the answer

Now the request itself. Prior Authorization Support, or P A S, defines how a provider's system sends a prior authorization request over FHIR, and how the answer comes back.

A Claim can ask for permission

PAS reuses two FHIR resources, Claim and ClaimResponse. They are used for real claims for payment, but FHIR also uses them to manage prior authorizations. A code on the claim, called use, says which. In the PAS guide, every mention of Claim and ClaimResponse means the prior authorization purpose.

Build, send, convert, answer

Here is the exchange. The provider's system builds a Bundle, with a Claim as its first entry and the supporting information the payer needs. It sends the Bundle in a Claim submit operation. The receiving system converts it to the older X twelve two seven eight transaction when needed, and sends it to the payer. The answer is converted back into a Bundle that starts with a ClaimResponse. The guide says this should happen within fifteen seconds, ideally less.

• Step 1 · Build a Bundle · A Claim first, plus supporting information. · box
• Step 2 · Claim submit · POST the Bundle. · share
• Step 3 · Convert if needed · To X12 278, and back. · gear
• Step 4 · Read the answer · A Bundle starting with ClaimResponse. · check

Approved, denied or pended

There are three kinds of answer. Approved: the item is authorized, and the response says when or under what circumstance the authorization ends. Denied: the response gives a specific reason. Pended: the payer could not decide in time. The client then waits for updates through a subscription, and each item keeps the same sequence number it had on the request, so the answer can be traced back.

• Yes · approved · with an end date or circumstance · check
• No · denied · with a specific reason · cross
• Wait · pended · updates arrive by subscription · clock

Check yourself

Pause and think. A prior authorization response is pended. What should the client do? The answer: wait for updates through a subscription.

• Wait for updates through a subscription
• Resubmit immediately every second
• Treat it as approved
• Treat it as denied

Keep these in mind

P A S reuses Claim and Claim Response for prior authorization. The Bundle goes in a Claim submit operation. Answers are approved, denied or pended. And pended answers update through a subscription.

• PAS reuses Claim and ClaimResponse for prior authorization
• The Bundle goes in a Claim submit operation
• Answers are approved, denied or pended
• Pended answers update through a subscription