Prior Authorization Support System API
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This asset is a component of MuleSoft Accelerator for Healthcare.
The MuleSoft Accelerator for Healthcare equips Payer, Provider, and Life Sciences organizations with foundational assets to accelerate their digital transformation journey. With our pre-built APIs, connectors, implementation templates, and reference architectures, IT teams can spend more time innovating rather than building from scratch.
Prior authorization (PA) is a process commonly used by payer organizations to manage healthcare costs. Providers need to receive advanced approval from payers before care delivery to ensure that patients/members receive treatments, testing, referrals, and devices appropriate for their specific conditions and that are covered by the specific health plan in which the member is enrolled.
The API specification supports the following operations on Prior Authorization Support:
| Operation | Definition |
|---|---|
| Claim Submission | The primary interaction supported by this implementation is submitting a prior authorization request and receiving back a response. To perform this, a Prior Authorization Support Request Bundle resource is constructed by the client system. That bundle will contain the Claim resource together with the various resources needed to support the population of the ASC X12 N 278 Prior authorization request. |
| Claim Inquiry | The prior authorization inquiry is used for polling pending authorization responses. This operation accepts Prior Authorization Support Inquiry Request Bundle and responds with Prior Authorization Support Inquiry Response Bundle with the results of the inquiry contained in the Bundle. |
Customers can use this this integration template to accelerate implementation.