Resource for medication that requires prior approval from insurer

1

Hi - I wanted to know which profile/resource is best fit for medication that requires prior auth approval from the insurer. It does not fit in the MedicationRequest profile since possible values for MedicationRequest.intent does not quite fit for the scenario. The closest one that matches is the definition that says ‘The request represents a request/demand and authorization for action’ but corresponding display says ‘Order’ which is not what this is. Appreciate any help on this.

2

You probably want to look at InsurancePlan - it defines the characteristics of coverage, and would generally include rules about what is covered and what the rules are for that coverage.

1 Like
3

Thanks. But in the case I have indicated there is no requirement around coverage. Its about provider submitting request for approval on a medication. The question is which resource will capture that request - irrespective of whether its approved or not (based on the coverage)? If you still lean on InsurancePlan I will check it in details but wanted to make sure I was able to convey the question correctly.

4

If you’re wanting a request for approval, that would be Claim - which covers both actual claims as well as prior authorizations and pre-determinations.

InsurancePlan talks about what a particular type of insurance would typically cover independent of who’s holding it, deductables paid, etc.

5

Thank you very much.

6

@BiswajitP, have a look at the Da Vinci Prior Authorization Implementation Guide: https://build.fhir.org/ig/HL7/davinci-pas/