Prior authorization evidence is distributed across diagnoses, observations, medications, procedures, reports, notes, and documents. FHIR provides consistent resource structures, but implementers still need criterion-level rules that account for clinical meaning, dates, status, and provenance.
Match the resource to the clinical statement
Condition commonly represents a diagnosis or problem, Observation a measurement or result, MedicationRequest an order, MedicationAdministration an administered dose, and Procedure an activity that occurred. DiagnosticReport can organize results, while DocumentReference points to clinical documents.
Selecting a resource by keyword is unsafe. The workflow must also inspect code systems, status, subject, encounter, performer, effective time, and relationships to other resources.
- Condition for diagnoses and clinical problems.
- Observation and DiagnosticReport for results.
- MedicationRequest and MedicationAdministration for therapy history.
- Procedure for completed interventions.
- DocumentReference for notes and external records.
Time and status change the answer
A policy may require a result within a defined lookback period, a completed treatment trial, or an active diagnosis. FHIR fields can represent these distinctions, but source systems populate them inconsistently.
Create normalization rules and data-quality checks before using the data for automated evidence suggestions. Show users when timing or status is ambiguous.
Preserve provenance
Every evidence match should retain the resource identifier, source system, relevant field, timestamp, and extraction method. If text was derived from a document, preserve the document and location used.
Provenance makes review faster and allows teams to correct mappings without losing the basis for earlier decisions.