The prior authorization journey

From an order to a decision

A clinician orders something. Does it need prior authorization? What does the payer need to see? And how is the request sent? Three Da Vinci guides answer those questions, one after another.

Four steps, three guides

Here is the journey. First, at the moment of ordering, the clinician's system asks the payer what applies. That is Coverage Requirements Discovery, C R D. Second, if documentation is needed, the system collects it. That is Documentation Templates and Rules, D T R. Third, the system sends the request to the payer. That is Prior Authorization Support, P A S. Fourth, the payer answers: approved, denied, or pended.

• Step 1 · Ask · CRD: what does the payer require? · search
• Step 2 · Collect · DTR: gather the documentation. · pencil
• Step 3 · Send · PAS: submit the request. · share
• Step 4 · Decide · Approved, denied or pended. · check

Each guide has one job

Each guide has one job. C R D makes coverage requirements available inside the provider's own software, at the point of care. D T R lets a payer express its documentation requirements in a way a computer can use, so the system can fill in what it already knows. And P A S sends the prior authorization request, directly from the system, using FHIR.

• CRD · Requirements at order time · search
• DTR · Collects the documentation · pencil
• PAS · Sends the request · share

Provider system and payer system

Two systems take part. The provider's system, usually an electronic health record, starts each step: it asks for coverage requirements, shows the questions, and submits the request. The payer's system answers: it returns coverage information, supplies its documentation rules, and makes the decision. FHIR is the shared language between them.

Check yourself

Pause and think. Which guide is about collecting the documentation a payer needs? The answer: Documentation Templates and Rules, D T R.

• Documentation Templates and Rules (DTR)
• Coverage Requirements Discovery (CRD)
• Prior Authorization Support (PAS)
• Provider Directory

Keep these in mind

C R D asks what the payer requires. D T R collects the documentation. P A S sends the request. And the payer approves, denies, or pends.

• CRD asks what the payer requires
• DTR collects the documentation
• PAS sends the request
• The payer approves, denies or pends