Prior Authorization API

Maintain a FHIR® API conformant with the technical requirements outlined in 45 CFR §170.215 that is populated with a list of all covered items and services offered by the payer that requires prior authorization to enable providers to determine if a prior authorization is required for a given item or service; identifies all required documentation that must be submitted in connection with the requests and supports the provider’s ability to auto-populate the documentation with information from the provider’s system; compiles necessary data elements to support HIPAA-compliant prior authorization transactions; and supports the payer’s ability to give responses in the form of status updates, approvals, denials (including reasons for denial), and/ or requests for more information. Prior authorization responses by payers must be within seven (7) calendar days for standard requests and within seventy-two (72) hours for expedited requests, unless applicable law, including state law, requires shorter timelines.