Provider prior authorization API – prior authorization support

The health IT developer demonstrates the Health IT Module supports the following capabilities as a client system in accordance with an implementation specification at § 170.215(j)(3) and the requirements in the § 170.315(j)(21) criterion:

1. PAS-1: Registration with a server system (e.g., payer system) to enable authentication, authorization, and FHIR operations as described in the “EHR PAS Capabilities Capability Statement.”
2. PAS-2: Authentication and authorization as a client with a server system using “Backend Services” in accordance with an implementation specification at § 170.215(c).
3. PAS-3: Submit a new prior authorization claim request to a server system using the “$submit” operation.
4. PAS-4: Support the following using the “$submit” operation for a claim request previously submitted to a server system:
   • Cancel an entire claim request.
   • Cancel an item within a claim request.
   • Revise an item within a claim request.
   • Add an additional item or supporting documentation to a claim request.
5. PAS-5: Manage claim request subscriptions to a server system including the ability to create, update, and delete subscriptions.
6. PAS-6: Consume claim request subscription notifications from a server system.
7. PAS-7: Check the status of a claim request previously submitted to a server system using the “$inquire” operation.

The tester verifies the Health IT Module supports the following capabilities as a client system in accordance with an implementation specification at § 170.215(j)(3) and the requirements in the § 170.315(j)(21) criterion:

1. PAS-1: Registration with a server system (e.g., payer system) to enable authentication, authorization, and FHIR operations as described in the “EHR PAS Capabilities Capability Statement.”
2. PAS-2: Authentication and authorization as a client with a server system using “Backend Services” in accordance with an implementation specification at § 170.215(c).
3. PAS-3: Submit a new prior authorization claim request to a server system using the “$submit” operation.
4. PAS-4: Support the following using the “$submit” operation for a claim request previously submitted to a server system:
   • Cancel an entire claim request.
   • Cancel an item within a claim request.
   • Revise an item within a claim request.
   • Add an additional item or supporting documentation to a claim request.
5. PAS-5: Manage claim request subscriptions to a server system including the ability to create, update, and delete subscriptions.
6. PAS-6: Consume claim request subscription notifications from a server system.
7. PAS-7: Check the status of a claim request previously submitted to a server system using the “$inquire” operation.

1. API-DOC-2: The health IT developer demonstrates the documentation described in step API-DOC-1 is available via a publicly accessible hyperlink that does not require preconditions nor additional steps to access.
   • API syntax;
   • Function names;
   • Required and optional parameters supported and their data types;
   • Return variables and their types/structures;
   • Exceptions and exception handling methods and their returns;
   • Mandatory software components;
   • Mandatory software configurations; and
   • All technical requirements and attributes necessary for registration.
2. API-DOC-1: The health IT developer supplies complete accompanying technical documentation for supported API server capabilities of client systems from an implementation specification adopted in § 170.215(j)(3). Such documentation should include as applicable:

1. API-DOC-1: The tester verifies the documentation supplied by the health IT developer completely describes the API server capabilities of client systems from an implementation specification adopted in § 170.215(j)(3) and includes the following as applicable:
   • API syntax;
   • Function names;
   • Required and optional parameters supported and their data types;
   • Return variables and their types/structures;
   • Exceptions and exception handling methods and their returns;
   • Mandatory software components;
   • Mandatory software configurations; and
   • All technical requirements and attributes necessary for registration.
2. API-DOC-2: The tester verifies the documentation described in step API-DOC-1 is available via a publicly accessible hyperlink that does not require preconditions nor additional steps to access.