PAS $submit FHIR API Specification
$submit Overview
InterSystems PAS (Prior Authorization Support) FHIR APIs are designed in compliance with the CMS-0057-F regulationsOpens in a new tab.
Refer to the Getting Started section for information on connectivity, authentication and how to get help. To use the FHIR APIs, you will need to know the base URL of the FHIR server you will be connecting to. You can also retrieve the capability statement for the service.
As part of the PAS APIs, a provider can use the $submit APIOpens in a new tab to submit a prior authorization request. This request is sent as a FHIR Bundle containing a PAS Claim and other referenced resources for adjudication by a payer. The $submit API can also be used to update or cancel a previously sent prior authorization claim.
Workflow
A typical workflow involving the submit operation might be:
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The provider collects necessary patient information, treatment details, and supporting documentation
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The provider’s system prepares a FHIR Bundle containing a PAS Claim resource and DocumentReference resources with supporting documentation
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The provider’s system sends the prepared Bundle to the payer’s PAS API endpoint using the $submit operation
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The payer’s system receives the request, validates the Bundle, and processes the Claim
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The payer’s system generates a PAS Claim ResponseOpens in a new tab resource with the adjudication decision and referenced resources, or an OperationOutcome resource
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The response Bundle is returned to the provider’s system
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The provider’s system receives the Claim Response, updates the patient’s record, and notifies the provider of the decision
Update or Cancel Claim
The services associated with a prior authorization may change after the initial claim has been submitted. As outlined in the PAS implementation guideOpens in a new tab (IG), a provider can use the $submit API to update or cancel a prior authorization request.
An update can cover four types of changes:
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Cancel the entire request
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Cancel item(s) within the request
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Update elements within the request
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Add items to the request
The IG outlines how a prior authorization request can be updated, by creating a new Bundle containing a new Claim resource with its own unique Claim.identifier. That resource should point to the previous claim using the Claim.related.claim element. The IG also provides sample requests for an initial requestOpens in a new tab and a subsequent update requestOpens in a new tab for a homecare service.
Endpoint: $submit
URL
The URL for this API is:
<BaseURL>/Claim/$submit
Optional Capabilities
None.
Endpoint Prerequisites
None.
Required Header Settings
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Content-Type: application/json+fhir
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Accept: application/json+fhir
Request Methods
Invokes $submit with a specified PAS Request Bundle. A FHIR PAS Request BundleOpens in a new tab can be passed in through the request body.
The request body must contain both Bundle.identifier.system and Bundle.identifier.value.
This method should be called synchronously. The implementation guideOpens in a new tab specifies that the entire process of submitting a prior authorization request and receiving a response should take no more than 15 seconds. This time frame includes the network transmission time for both the request and the response. Faster processing times are preferable to improve efficiency and user experience.
Query Parameters
None.
Request Body
The body of the request is the FHIR PAS Request BundleOpens in a new tab, which contains a PAS Claim resource. Example PAS Claim resources can be found on the Resource Profile: PASClaim – ExamplesOpens in a new tab page.
Success Response
The request succeeded. The body of the response is the FHIR PAS Response BundleOpens in a new tab.
Error Responses
Error due to a bad request. The response body contains a FHIR OperationOutcome resource with further details.
If the identifier array stored in Claim.provider.identifier[x].value does not contain a value that matches the provider_identifier property of the OAuth 2.0 token, the error text will state “Claim.provider.identifier array must contain an identifier that matches the 'provider_identifier' claim of the OAuth 2.0 token”.
Possible causes of a bad request include:
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The claim identifier is a duplicate and has already been processed
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The provider identifier does not match that in the OAuth 2.0 token
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The request contains duplicate Bundle identifiers
The authenticated user does not have access to a resource needed to process the request.
The authenticated user is not authorized to use the requested resource.
The server cannot process the request because the media type specified in the request's Content-Type or Accept headers, application/fhir+json, is not supported.
A generic error message, returned when no more specific message is suitable.