Submit a prior authorization request using Da Vinci PAS Claim/$submit and handle payer responses

In-depth guide

Steps

1. Construct the PAS request Bundle: a transaction Bundle containing a Claim resource (profiled as PAS-RequestClaim), with supporting clinical resources (Condition, ServiceRequest, Coverage, Patient, Practitioner) as additional Bundle entries
2. Invoke the type-level operation: POST [base]/Claim/$submit with the request Bundle as the body; this is a type-level operation on Claim, not a base-level system operation
3. Parse the synchronous response Bundle: if the payer returns a ClaimResponse immediately, inspect ClaimResponse.outcome ('complete', 'queued') and ClaimResponse.item[].adjudication for approved, denied, or pended item decisions
4. If the response is 'queued' (pended), the ClaimResponse will include a ClaimResponse.processNote with a reference identifier or the server returns a polling location; use PAS $inquire (POST [base]/Claim/$inquire) with the pended claim identifier to check status
5. Map the approved/denied response back through an X12 278 Response intermediary if required by the payer's clearinghouse; the PAS IG defines the mapping between FHIR ClaimResponse elements and X12 278 response segments
6. Handle a final 'denied' adjudication by storing the denial reason from ClaimResponse.item[].adjudication.reason and initiating an appeal workflow or alternative treatment path