Prior Authorization Support defines FHIR profiles and operations for exchanging authorization requests and responses. It helps provider and payer systems package administrative and clinical content consistently while accommodating the transaction requirements of the United States market.
What belongs in a PAS request
A request needs patient, coverage, provider, service, diagnosis, and timing information plus the supporting evidence needed for review. Stable identifiers allow both organizations to reconcile updates and responses with the correct case.
Supporting information may include structured FHIR resources and documents. The implementation should preserve the relationship between every attachment and the criterion it supports.
- Validate required profiles and terminology.
- Prevent duplicate submissions with durable identifiers.
- Track request, response, and update timestamps.
- Retain the exact payload used for audit and troubleshooting.
Responses must drive operations
Approval, denial, pending, and additional-information responses need to become explicit case events. A technically valid response that lands in an unmonitored queue does not improve the authorization process.
Map response details to owners, due dates, and next actions. Keep payer messages and adjudication identifiers visible to users who resolve the case.
Test beyond the happy path
Conformance testing should include invalid members, conflicting coverage, changed services, duplicate requests, large attachments, timeouts, and partial responses. Teams also need reconciliation procedures for portal or phone activity outside the API.
Operational readiness is achieved when users can recover from these conditions without losing case history or submitting unsupported information.