Where to look: a finder

Where to look

You have now seen the rule, the four A P Is, and the three Da Vinci guides. This lesson is a finder: given a question, where do you look?

A question, and where it lives

Start with the questions. What does the payer need for this order? Coverage Requirements Discovery. What documentation do I collect? Documentation Templates and Rules. How do I send the request? Prior Authorization Support. Where can a patient see their prior authorizations? The Patient Access A P I. Which providers can see a patient's claims? The Provider Access A P I. And what happens when a patient changes plans? The Payer to Payer A P I.

• What does the payer need? · CRD · search · navy
• What do I collect? · DTR · pencil · navy
• How do I send it? · PAS · share · navy
• Patient sees their data · Patient Access API · person · amber
• Providers see claims · Provider Access API · building · amber
• Patient changes plans · Payer-to-Payer API · globe · slate

The standards underneath

Underneath the A P Is sit named standards. FHIR release four point zero point one is the base. U S Core and the United States Core Data for Interoperability say which data and profiles to use. SMART, with OpenID Connect, handles authorization and sign in. And FHIR Bulk Data Access is for moving large sets of data. Check the current rule for the exact versions.

• The base standard · FHIR release 4 · box · navy
• Which data to share · US Core and USCDI · file · navy
• Authorization and sign-in · SMART and OpenID Connect · lock · amber
• Large data sets · FHIR Bulk Data Access · layers · slate

Check yourself

Pause and think. A clinician wants to know, while placing an order, whether prior authorization is needed. Where do you look? The answer: Coverage Requirements Discovery.

• Coverage Requirements Discovery (CRD)
• The Payer-to-Payer API
• The Provider Directory
• X12 278 only

Keep these in mind

There are four A P Is: patient, provider, payer to payer, and prior authorization. C R D, D T R and P A S carry a prior authorization. The process rules cover time limits, reasons and metrics. And you should always check the current rule for dates and versions.

• Four APIs: patient, provider, payer-to-payer, prior authorization
• CRD, DTR and PAS carry a prior authorization
• Process rules cover time limits, reasons and metrics
• Check the current rule for dates and versions