Send Prior Authorization
Overview
This endpoint is designed to streamline the submission of prior authorization requests for medications or treatments. It requires various key pieces of information about the patient, including demographics, insurance details, and the prescription in question. Additionally, the submission should include supporting evidence, such as visit notes, lab results, and intake forms, to justify the need for the prescribed medication or treatment.
How to Use
To effectively use this endpoint, please ensure the following information is included in your request:
- Patient Demographics: Essential details such as the patient’s name, date of birth, and contact information.
- Insurance Details: A photo or scan of the patient’s insurance card (preferably front and back), including the group number, payer, membership number and RX details. If an image is not available, or the patient provided extra information not on their card (such as rx codes) you can also provide this structured data in the API.
- Prescription Information: Detailed data on the prescribed medication or treatment, such as drug name, dosage, and administration instructions.
- Evidence: Critical supporting documents and data such as visit notes and laboratory results. This section is particularly versatile, allowing for a variety of formats and contents to support the authorization request.
Given the diverse nature of medical records and evidence, our API is built to accommodate a wide range of data formats. Structured data can be filled into predefined fields, while unstructured data, such as additional JSON content about the patient, can be included in the content block within the evidence objects. This flexibility ensures that even non-standardized data can be effectively utilized in the prior authorization process.
In the future we will support uploading files and scans, such as PDFs, images, and other documents, to the evidence section. Currently these are not utilized in the answering flow, but we will be adding support for them in the future. The API does support uploading these, and in a future version of our answering model they will be used.
Response
After submitting a request, the system processes the data and returns a response indicating either the successful reception of the request or detailing any errors or additional information needed. Our advanced AI algorithms will analyze the provided information, including any uploaded files or scans, extracting and utilizing relevant details to facilitate the authorization process.
You’ll notice in the response error section at the bottom of this page that there are several possible errors that can occur. Particularly during the ramp up period you’ll likely see the daily_prior_auth_request_limit_reached error. We’re still in the process of reaching 100% plan coverage, so seeing the unsupported_patient error is also expected. We want to make integrating as easy as possible, so the details of these error codes can generally be ignored. You’ll likely want to process them all the same way as detailed below.
Building the Integration
We’d suggested taking the following approach when integrating:
- Make the API request for all prior authorizations that you need to submit, and let us handle the ramp up on our end. i.e. We’d recommend not feature flagging or limiting this to certain patients. We have a daily limit that starts off at just 5 requests that we can increase rapidly. Using this approach allows us to work with your ops team to gradually increase the volume we handle as we see successful responses from the insurance companies.
- If you receive an error code, fallback to your companies existing process for handling prior authorizations. We’ll gradually reduce the number of errors you receive as we ramp up to 100% coverage.
As a developer reading these docs we understand it might be difficult to know what data to provide and how best to structure it. Please know that we at Develop Health are here to help! A member of our engineering team will happily work with you to ensure you’re providing the right data in the right format.
Authorizations
Bearer authentication header of the form Bearer <token>
, where <token>
is your auth token.
Body
Whether this prior authorization request is for training purposes. If true, the request will not be sent through the standard workflow.
Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9'
A collection of evidence items supporting the authorization request. Any other supporting evidence that doesn't fit into one of the explicitly declared fields above can be added here.
Demographic information for the patient
Insurance information for the patient. We will extract the required information from the insurance card images you provide. Please provide both the front and the back of the card. This is optional if you provide insurance_content
, but highly recommended to ensure best results.
Insurance information for the patient. Values provided here will be used in combination with those extracted from any insurance cards provided. We recommend providing this information when available to ensure best results. If you provide both insurance
and insurance_content
, the values extracted from insurance
will be used and the values provided here will be used as a fallback.
Information regarding the prescription this prior authorization is being created for.
Details of the healthcare provider who created the prescription.
Information about the pharmacy where the prescription will be filled.
List of questionnaires. This is the best place to send structured Q&A format data, such as intake forms, etc.
List of visit notes.
Specifies the simulated outcome for a completed prior authorization. Setting this field will instantly complete the prior authorization request and send a webhook with the value of this field. You will not be charged for these requests and you will not be sent the prior auth for manual review.
Response
success
Error payload of the response, containing details of the error that occurred during the creation of the prior authorization request.
Data payload of the response, containing details of the created prior authorization request, or None if the request was unsuccessful.