Payerbox Docs

PAS

The Payerbox PAS API enables direct submission of prior authorization requests from EHR/UM systems using FHIR. Built on the HL7 Da Vinci Prior Authorization Support Implementation Guide.

When combined with CRD and DTR, PAS ensures authorizations are submitted when necessary with all required information for initial decision-making.

Payerbox implements Da Vinci PAS STU 2.1.0. See Compliance / CMS-0057 for the regulatory context.

Lifecycle

PAS supports three operations forming a typical flow:

  1. Claim/$submit — Submit a prior authorization request as a FHIR Bundle. Payerbox returns a ClaimResponse with outcome = "queued"; the payer's UM system later updates the same ClaimResponse to convey the decision via the reviewAction extension (e.g. X12 code A1 = certified / approved, A3 = not certified / denied, A4 = pended).
  2. Claim/$inquire — Poll the status of a previously submitted request.
  3. $submit-attachment — (Optional) Submit clinical documentation associated with an existing prior authorization, when the payer requests additional information.

The Da Vinci PAS Request Bundle profile requires exactly one focal Claim per Bundle — the underlying X12 278 transaction carries one prior authorization per BHT. Submit multiple requests with multiple Claim/$submit calls.

Authentication

PAS uses SMART Backend Services Authorization. The payer admin provisions Client credentials per partner integration (EHR vendor, UM vendor, integrator). See API Reference / Authentication for the onboarding and token exchange flow.

Example

Submit a prior authorization:

POST /fhir/Claim/$submit
Content-Type: application/json
Accept: application/json

{
  "resourceType": "Bundle",
  "meta": { "profile": ["http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-pas-request-bundle"] },
  "type": "collection",
  "entry": [
    { "resource": { "resourceType": "Claim", "id": "claim-1", "status": "active", "use": "preauthorization", "patient": { "reference": "Patient/patient-1" }, "insurer": { "reference": "Organization/payer-org-1" } } },
    { "resource": { "resourceType": "Patient", "id": "patient-1", "name": [{ "family": "Smith", "given": ["John"] }] } },
    { "resource": { "resourceType": "Coverage", "id": "coverage-1", "status": "active", "beneficiary": { "reference": "Patient/patient-1" } } }
  ]
}

{
  "resourceType": "Bundle",
  "type": "collection",
  "entry": [
    {
      "resource": {
        "resourceType": "ClaimResponse",
        "id": "response-1",
        "status": "active",
        "use": "preauthorization",
        "outcome": "queued",
        "request": { "reference": "Claim/claim-1" }
      }
    }
  ]
}

Full Bundle profiles, all parameters, and edge cases: Claim/$submit. For status checks and attachment workflows: Claim/$inquire, $submit-attachment.

Last updated: