Prior Authorization API

Everything you need to know about the Prior Authorization API including its purpose, who it affects, and when it goes into effect.

Prior Authorization visualized with a healthcare worker on a laptop with a document on the screen showing a signature and checkmark

What Is The 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.

Who Does This API Impact?

When Does It Take Effect?

What Should You Do Next?

Connect with 1upHealth to learn more about the Prior Authorization API and how we can help you prepare for when it goes into effect.

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