> ## Documentation Index
> Fetch the complete documentation index at: https://docs.develophealth.ai/llms.txt
> Use this file to discover all available pages before exploring further.
# 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.
* **Prescriber Information**: Details about the prescribing healthcare provider, including the prescriber's name, NPI (National Provider Identifier), contact information, and practice or facility details.
* **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.
We highly recommend you talk to a member of your company who actively submits prior authorizations when collecting the data for this endpoint. For the system to work effectively, we require the **exact** same data that those staff members currently have access to. A great test is to collect the data and see if the staff member is able to use that data alone to submit a new prior authorization through your existing system.
## 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.
## Building the Integration
We suggest taking the following approach when integrating:
1. Make the API request for *all* prior authorizations that you need to submit, and let us handle coverage on our end. We'd recommend not feature flagging or limiting this to certain patients. Using this approach allows us to work with your ops team to resolve unsupported scenarios while giving you a complete view of which requests Develop Health can process.
2. If you receive an error code, fallback to your company's existing process for handling prior authorizations. We'll gradually reduce the number of errors you receive as we expand 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.
## OpenAPI
````yaml post /prior-authorization
openapi: 3.1.0
info:
title: Develop Health Public API
description: Develop Health Public API
version: '1.0'
servers:
- url: https://api.develophealth.ai
security: []
paths:
/prior-authorization:
post:
tags:
- public-api
summary: Create Prior Auth Route
operationId: create_prior_auth_route_prior_authorization_post
requestBody:
content:
application/json:
schema:
allOf:
- $ref: '#/components/schemas/CreatePriorAuthRequest'
title: Data
examples:
- diagnoses:
- code: E66.9
evidence:
- content:
bmi_value: 32
date_measured: '2023-11-10'
date_created: '2023-11-10T10:15:00'
title: BMI Chart
- content:
medication_name: Metformin
response: No significant weight loss
date_created: '2023-11-10T10:15:00'
title: Previous Medication History
patient:
address:
street: 123 Health St.
city: Wellness
state_province: CA
zip_postal_code: '12345'
country: USA
date_of_birth: '1980-01-01'
email: johndoe@email.com
first_name: John
last_name: Doe
gender: male
internal_id: '123456'
phone: 123-456-7890
insurance:
- file_content: >-
iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg==
- file_content: >-
iVBORw0KGgoAAAANSUhEUgAAAAEAAAABCAYAAAAfFcSJAAAADUlEQVR42mP8z8BQDwAFgwJ/lzvN2QAAAABJRU5ErkJggg==
prescription:
days_supply: 30
quantity: 2
directions: Inject subcutaneously once a week
drug_name: Wegovy
strength: 0.25 mg/0.5 mL (0.25 mg dose)
dose_form: injectable
route_of_administration: subcutaneous
extra:
prescribing_information: >-
Prescribed for weight management in patients with
obesity
prescription_date: '2024-02-14T05:46:07.764000'
provider:
address:
street: 456 Care Blvd.
city: Healtown
state_province: CA
zip_postal_code: '67890'
country: USA
fax: 987-654-3211
first_name: Alice
internal_id: provider_12345
last_name: Smith
npi: '1234567890'
phone: 987-654-3210
pharmacy:
name: Walgreens
address:
street: 789 Pharmacy Ave.
city: Medtown
state_province: MD
zip_postal_code: '12345'
country: USA
questionnaires:
- questions:
- answer: >-
I usually eat a balanced diet and exercise 3 times a
week.
question: >-
Please describe your current diet and exercise
routine.
- answer: >-
Yes, I have tried metformin without significant
results.
question: >-
Have you previously tried other weight loss
medications?
date_created: '2023-11-01T08:00:00'
visit_notes:
- content: >-
Patient presents with a BMI of 32, indicating obesity.
Recommended to start Wegovy for weight management.
date_created: '2023-11-10T10:00:00'
priority: 2
required: true
responses:
'200':
description: Successful creation of a prior authorization
content:
application/json:
schema:
$ref: '#/components/schemas/CreatePriorAuthResponse'
example:
status: success
data:
id: pa_sdkfj3f
'400':
description: API error during creation of the prior authorization request
content:
application/json:
example:
status: error
error:
title: Unsupported Drug
description: >-
The drug you submitted is not yet supported for prior
authorization.
code: unsupported_drug
'409':
description: >-
Conflict: prescription message already linked to existing prior
authorization
content:
application/json:
example:
status: error
error:
title: Prescription Already Linked
description: >-
The prescription_message_id provided is already linked to a
prior authorization request that is in progress or has
already been completed as approved. The existing PA request
must be cancelled before submitting a new request for the
same prescription.
code: prescription_message_already_linked
existing_prior_auth_request_id: par_example123
'422':
description: Validation Error
content:
application/json:
schema:
$ref: '#/components/schemas/HTTPValidationError'
security:
- FronteggJWTAuthentication: []
components:
schemas:
CreatePriorAuthRequest:
properties:
diagnoses:
items:
$ref: '#/components/schemas/Diagnosis'
type: array
title: Diagnoses
description: Clinical diagnoses for the patient in ICD-10 format. i.e. 'E66.9'
evidence:
items:
$ref: '#/components/schemas/EvidenceItem'
type: array
title: Evidence
description: >-
A collection of evidence items supporting the authorization request.
Any supporting evidence that doesn't belong in the other predefined
fields can be added here.
patient:
allOf:
- $ref: '#/components/schemas/Patient'
title: Patient
description: Demographic information for the patient
insurance:
items:
$ref: >-
#/components/schemas/api__schemas__platform__public_api__insurance_document__InsuranceDocument
type: array
title: Insurance
description: >-
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_content:
allOf:
- $ref: '#/components/schemas/PartialInsuranceInfo'
title: Insurance Content
description: >-
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 provided here will be used and the
values extracted from `insurance` will be used as a fallback.
prescription:
anyOf:
- $ref: '#/components/schemas/CodedPrescription'
- $ref: '#/components/schemas/Prescription'
title: Prescription
description: >-
Information regarding the prescription this prior authorization is
being created for. Required unless `ndp_submission` is provided with
a `prescription_message_id`. Prefer coded prescriptions when NDCs
are available.
provider:
allOf:
- $ref: '#/components/schemas/Provider'
title: Provider
description: Details of the healthcare provider who created the prescription.
pharmacy:
allOf:
- $ref: '#/components/schemas/Pharmacy'
title: Pharmacy
description: >-
Information about the pharmacy where the prescription will be
filled.
questionnaires:
items:
$ref: '#/components/schemas/Questionnaire'
type: array
title: Questionnaires
description: >-
List of questionnaires. This is the best place to send structured
Q&A format data, such as intake forms, etc.
visit_notes:
items:
$ref: '#/components/schemas/VisitNote'
type: array
title: Visit Notes
description: List of visit notes.
ndp_submission:
$ref: '#/components/schemas/PriorAuthRequestNDPSubmission'
resubmission_info:
$ref: '#/components/schemas/PriorAuthRequestResubmissionInfo'
appeal_details:
allOf:
- $ref: '#/components/schemas/AppealDetails'
title: Appeal Details
description: >-
Details for submitting an appeal of a previously denied prior
authorization. When provided, the request will be processed as an
appeal.
mock_result:
anyOf:
- $ref: '#/components/schemas/PriorAuthMockResultApproved'
- $ref: '#/components/schemas/PriorAuthMockResultDenied'
- $ref: '#/components/schemas/PriorAuthMockResultOther'
- $ref: '#/components/schemas/PriorAuthMockResultNotSubmitted'
title: Mock Result
description: >-
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.
priority:
allOf:
- $ref: '#/components/schemas/Priority'
description: >-
Specifies the priority of the prior authorization request. This is
used to determine the order in which requests are processed. Lower
values indicate higher priority.
default: 2
trigger_benefit_verification:
allOf:
- $ref: '#/components/schemas/TriggerBenefitVerificationConfig'
title: Trigger Benefit Verification
description: >-
If provided and enabled, triggers a benefit verification to check
drug coverage before the PA proceeds.
type: object
required:
- diagnoses
- patient
- provider
title: CreatePriorAuthRequest
description: >-
Represents a request for creating a prior authorization for a
medication. This includes detailed
information about the patient, their diagnosis, prescribed medication,
evidence supporting the need for treatment,
insurance details, and responses to relevant questionnaires.
CreatePriorAuthResponse:
properties:
status:
anyOf:
- type: string
enum:
- success
- type: string
enum:
- error
title: Status
default: success
error:
allOf:
- $ref: '#/components/schemas/CreatePriorAuthResponseError'
title: Error
description: >-
Error payload of the response, containing details of the error that
occurred during the creation of the prior authorization request.
data:
allOf:
- $ref: '#/components/schemas/CreatePriorAuthResponseData'
title: Data
description: >-
Data payload of the response, containing details of the created
prior authorization request, or None if the request was
unsuccessful.
type: object
title: CreatePriorAuthResponse
description: >-
Models the response received upon creating a prior authorization
request.
HTTPValidationError:
properties:
detail:
items:
$ref: '#/components/schemas/ValidationError'
type: array
title: Detail
type: object
title: HTTPValidationError
Diagnosis:
properties:
code:
type: string
title: Code
description: ICD-10 code for the diagnosis. i.e. 'E66.9'
type: object
required:
- code
title: Diagnosis
description: Represents a medical diagnosis with a code and description.
EvidenceItem:
properties:
asset:
allOf:
- $ref: '#/components/schemas/Asset'
title: Asset
description: >-
File asset containing the evidence. This is an alternative to the
`content` field which must be unused or null if `asset` is provided.
content:
anyOf:
- type: object
- type: string
title: Content
description: >-
Detailed content of the evidence, which varies based on the type of
evidence.
date_created:
type: string
format: date-time
title: Date Created
description: >-
The date and time (if available) when the evidence was created. This
is important for ensuring we have an accurate timeline of the
patient's history.
title:
type: string
title: Title
description: >-
Title of the evidence. This will be shown to users in the platform
UI so it's recommended to give it a name that would be meaningful to
them, such as 'Intake Form'
type: object
required:
- date_created
- title
title: EvidenceItem
description: >-
Represents an item of evidence, which can include an associated digital
asset.
Patient:
properties:
address:
allOf:
- $ref: '#/components/schemas/Address'
title: Address
description: The patient's postal address
date_of_birth:
type: string
format: date
title: Date Of Birth
description: The patient's date of birth
email:
type: string
format: email
title: Email
description: The patient's email address
first_name:
type: string
minLength: 1
title: First Name
description: The patient's first name
last_name:
type: string
minLength: 1
title: Last Name
description: The patient's last name
gender:
allOf:
- $ref: '#/components/schemas/Gender'
description: The patient's gender
internal_id:
type: string
minLength: 1
title: Internal Id
description: >-
Your internal ID for this patient. This is used for linking all of
the requests for a given patient.
mrn:
type: string
title: Mrn
description: Medical record number
phone:
type: string
title: Phone
description: The patient's phone number
type: object
required:
- address
- date_of_birth
- first_name
- last_name
- gender
- internal_id
title: Patient
description: Represents patient information.
api__schemas__platform__public_api__insurance_document__InsuranceDocument:
properties:
file_content:
type: string
title: File Content
type: object
required:
- file_content
title: InsuranceDocument
description: |-
Represents an insurance document.
Attributes:
file_content (str): The content of the insurance document,
base64 encoded
PartialInsuranceInfo:
properties:
client_name:
type: string
title: Client Name
description: The client/employer name.
group_number:
type: string
title: Group Number
description: The group number on the card.
member_name:
type: string
title: Member Name
description: The member name on the card.
member_number:
type: string
title: Member Number
description: The member number on the card.
payer_name:
type: string
title: Payer Name
description: >-
The payer name on the card. This field is not normalized, so the
same plan may have different names depending on the way it appears
on the card. i.e. 'United Healthcare', 'United', 'United Health'
could all appear
plan_name:
type: string
title: Plan Name
description: >-
The plan name on the card. This field is not normalized, so the same
plan may have different names depending on the way it appears on the
card
rx_bin:
type: string
title: Rx Bin
description: The Rx BIN number on the card.
rx_group:
type: string
title: Rx Group
description: The Rx group number on the card.
rx_pcn:
type: string
title: Rx Pcn
description: The Rx PCN number on the card.
type: object
title: PartialInsuranceInfo
CodedPrescription:
properties:
ndc:
type: string
pattern: >-
^(\d{5}-?\d{4}-?\d{2}|\d{4,5}-\d{3,4}-\d{1,2}|\d{5}-?\d{4}|\d{4,5}-\d{3,4})$
title: Ndc
description: The NDC of the medication. Both 10 and 11-digit NDCs are supported.
examples:
- 00169-4505-14
- 0169-4505-14
- 169450514
directions:
type: string
minLength: 1
title: Directions
description: Instructions on how the medication should be taken.
examples:
- Inject 0.25 mg under the skin once weekly
- Take 1 tablet by mouth daily
quantity:
type: integer
title: Quantity
description: The quantity of the medication.
examples:
- 1
quantity_unit_of_measure:
type: string
title: Quantity Unit Of Measure
description: >-
The unit of measurement for the quantity of the medication (subset
code C89510). Either an NCIt code or the name of the term. If not
provided, C38046 (Unspecified) will be used.
default: C38046
examples:
- C48504
- Kit
days_supply:
type: integer
title: Days Supply
description: The number of days the prescription will be expected to last.
examples:
- 28
- 30
- 90
expected_length_of_therapy:
type: string
title: Expected Length Of Therapy
description: >-
The expected length of therapy for the prescribed drug. Defaults to
'Until No Longer Needed' if not provided.
examples:
- Until No Longer Needed
- 12 months
- 6 weeks
extra:
type: object
title: Extra
description: >-
An optional dictionary containing additional information related to
the drug or future prescription.
examples:
- notes: Patient prefers brand name
prior_auth_reference: ABC123
prescription_date:
type: string
format: date-time
title: Prescription Date
description: The date the prescription was issued
type: object
required:
- ndc
- directions
- quantity
- days_supply
- prescription_date
title: CodedPrescription
description: |-
Represents a prescription issued by a healthcare provider. This is an
alternative to the Prescription model that is more closely aligned with
NCPDP standards and helps reduce any confusion on the payer-side. Prefer
this model over Prescription when NDCs are available.
Prescription:
properties:
days_supply:
type: integer
title: Days Supply
description: The number of days the prescription will be expected to last.
quantity:
type: integer
title: Quantity
description: The quantity of the medication.
directions:
type: string
minLength: 1
title: Directions
description: Instructions on how the medication should be taken.
drug_name:
type: string
minLength: 1
title: Drug Name
description: The name of the medication.
strength:
type: string
minLength: 1
title: Strength
description: The strength of the medication.
dose_form:
allOf:
- $ref: '#/components/schemas/DoseForm'
description: The form of the medication.
route_of_administration:
allOf:
- $ref: '#/components/schemas/RouteOfAdministration'
description: The route of administration for the medication.
extra:
type: object
title: Extra
description: >-
An optional dictionary containing additional information related to
the drug or future prescription.
expected_length_of_therapy:
type: string
title: Expected Length Of Therapy
description: >-
The expected length of therapy for the prescribed drug. Defaults to
'Until No Longer Needed' if not provided.
examples:
- Until No Longer Needed
- 12 months
- 6 weeks
prescription_date:
type: string
format: date-time
title: Prescription Date
description: The date the prescription was issued
type: object
required:
- days_supply
- quantity
- directions
- drug_name
- strength
- dose_form
- route_of_administration
- prescription_date
title: Prescription
description: |-
Represents a prescription issued by a healthcare provider. Prefer
CodedPrescription when NDCs are available.
Provider:
properties:
address:
allOf:
- $ref: '#/components/schemas/OptionalAddress'
title: Address
description: The provider's postal address.
fax:
type: string
title: Fax
description: The provider's fax number.
first_name:
type: string
minLength: 1
title: First Name
description: The provider's first name.
internal_id:
type: string
title: Internal Id
description: >-
Your internal ID for this provider. This is used for linking all of
the requests for a given provider.
last_name:
type: string
minLength: 1
title: Last Name
description: The provider's last name.
npi:
type: string
minLength: 1
title: Npi
description: The provider's NPI.
phone:
type: string
title: Phone
description: The provider's phone number.
type: object
required:
- address
- first_name
- last_name
- npi
title: Provider
description: Represents a healthcare provider.
Pharmacy:
properties:
name:
type: string
minLength: 1
title: Name
description: The name of the pharmacy.
address:
$ref: '#/components/schemas/Address'
type: object
required:
- name
title: Pharmacy
description: |-
Represents a pharmacy.
Attributes:
name (str): The name of the pharmacy.
address (Address): The pharmacy's postal address.
Questionnaire:
properties:
questions:
items:
$ref: '#/components/schemas/Question'
type: array
title: Questions
description: A list of questions included in the questionnaire.
date_created:
type: string
format: date-time
title: Date Created
description: >-
The date and time when the questionnaire was answered. This is
important for ensuring we have an accurate timeline of the patient's
history.
type: object
required:
- questions
- date_created
title: Questionnaire
VisitNote:
properties:
title:
type: string
minLength: 1
title: Title
description: >-
The title of the visit note. This is optional and can be used to
give the note a meaningful name, such as 'Initial Consultation'.
content:
type: string
minLength: 1
title: Content
description: The content of the visit note.
date_created:
type: string
format: date-time
title: Date Created
description: >-
The date and time (if available) when the visit note was created.
This is important for ensuring we have an accurate timeline of the
patient's history.
type: object
required:
- content
- date_created
title: VisitNote
description: Represents a note made during a patient visit.
PriorAuthRequestNDPSubmission:
properties:
prescription_message_id:
type: string
minLength: 1
title: Prescription Message Id
description: The Surescripts message ID for the prescription transfer.
ignore_eligibility_check_error:
type: boolean
title: Ignore Eligibility Check Error
description: >-
If set to True, error responses from the eligibility check will not
terminate the PA request.
submit_pa_with_eligibility_check_government_plan:
type: boolean
title: Submit Pa With Eligibility Check Government Plan
description: >-
If set to True, the PA request will be submitted even if the
eligibility check reveals the patient has only government insurance
plan(s).
default: false
preferred_pharmacy_ncpdp_id:
type: string
pattern: ^\d{7}$
title: Preferred Pharmacy Ncpdp Id
description: >-
The NCPDP ID of the preferred pharmacy where the prescription will
be transferred after the PA request has been approved.
preferred_pharmacy_details:
type: string
title: Preferred Pharmacy Details
description: >-
Free-text pharmacy preference information (e.g. 'CVS Pharmacy, 123
Main St, Portland OR 97201'). At least one of
preferred_pharmacy_ncpdp_id or preferred_pharmacy_details must be
provided.
type: object
required:
- prescription_message_id
- ignore_eligibility_check_error
title: PriorAuthRequestNDPSubmission
description: >-
Configuration for processing the prescription associated with this PA
request.
This field should only be provided when a prescription has been sent to
Develop
Health's non-dispensing pharmacy.
PriorAuthRequestResubmissionInfo:
properties:
previous_prior_auth_request_id:
type: string
title: Previous Prior Auth Request Id
description: Identifier of the previous prior authorization request.
note:
type: string
title: Note
description: >-
Reason for resubmission or additional instructions for this attempt.
Required unless `appeal_details` is provided.
quantity_limit_exception_reason:
type: string
title: Quantity Limit Exception Reason
description: >-
Explanation for requesting an exception to the plan's quantity
limit. Required when resubmitting due to a quantity limit denial.
type: object
title: PriorAuthRequestResubmissionInfo
description: Information provided when resubmitting a prior authorization request.
AppealDetails:
properties:
appeal_letter:
allOf:
- $ref: '#/components/schemas/AppealLetter'
title: Appeal Letter
description: Appeal letter file to submit with the appeal.
is_urgent:
type: boolean
title: Is Urgent
description: Whether this appeal should be treated as urgent.
default: false
type: object
required:
- appeal_letter
title: AppealDetails
description: >-
Details for submitting an appeal of a previously denied prior
authorization.
PriorAuthMockResultApproved:
properties:
result:
type: string
enum:
- Approved
const: Approved
title: Result
description: The Prior Authorization has been approved.
default: Approved
detail_code:
allOf:
- $ref: '#/components/schemas/PriorAuthOutcomeApprovalDetail'
description: >-
A code indicating the reason for the prior auth outcome. The
possible values are:
- **prior_auth_not_required**: A prior authorization is not
required.
- **approval**: The prior authorization request has been approved.
- **existing_approval**: An active prior authorization approval
already exists for the patient.
prescription_transfer_error_code:
allOf:
- $ref: '#/components/schemas/PrescriptionTransferErrorCode'
description: >-
This field is only used if the
ndp_submission.preferred_pharmacy_ncpdp_id was provided in the
request. If provided, a prescription transfer error will be mocked.
Otherwise / by default, a successful transfer will be mocked.
type: object
title: PriorAuthMockResultApproved
description: Represents a mock result for a prior authorization request.
PriorAuthMockResultDenied:
properties:
result:
type: string
enum:
- Denied
const: Denied
title: Result
description: The Prior Authorization has been denied.
default: Denied
detail_code:
allOf:
- $ref: '#/components/schemas/PriorAuthOutcomeDenialDetail'
description: >-
A code indicating the reason for the prior auth outcome. The
possible values are:
- **formulary_alternative_preferred**: The formulary alternative is
preferred.
- **medical_necessity_criteria_not_met**: The medical necessity
criteria are not met.
- **plan_exclusion**: The drug is excluded by the plan.
- **step_therapy_criteria_not_met**: The step therapy criteria are
not met.
- **existing_denial**: An existing denial is on file for this
medication and patient. Please follow the appeals process if you
wish to adjust this outcome
- **coverage_limits_exceeded**: The coverage limits have been
exceeded for this patient's plan.
- **prior_weight_loss_program_required**: The patient has not
completed the required weight loss program prior to therapy.
- **unknown**: The prior authorization request has been denied.
client_code:
type: string
title: Client Code
description: >-
A client-specific outcome code for the denial. This will be returned
in the outcome response.
type: object
title: PriorAuthMockResultDenied
description: Represents a mock result for a prior authorization request.
PriorAuthMockResultOther:
properties:
result:
type: string
enum:
- Other
const: Other
title: Result
description: >-
The Prior Authorization has completed without an approval/denial
determination.
default: Other
detail_code:
allOf:
- $ref: '#/components/schemas/PriorAuthOutcomeOtherDetailPublic'
description: >-
A code indicating the reason for the prior auth outcome. The
possible values are:
- **coverage_inactive**: The patient's coverage has expired.
- **coverage_not_yet_started**: The patient's coverage has not yet
started.
- **no_pharmacy_benefits**: The patient's insurance does not include
pharmacy benefits.
- **payer_unable_to_locate_member**: The payer could not locate the
member in their system.
- **npi_taxonomy_ineligible**: The payer rejected the request
because the prescriber's NPI taxonomy, provider type, specialty, or
credentials are not eligible to submit this prior authorization.
- **payer_reported_invalid_patient_info**: The payer located the
patient in their system but some submitted patient information does
not match.
- **duplicate_request**: The request is a duplicate. Please cancel
the existing request and resubmit if needed.
- **prior_auth_not_required**: A prior authorization is not required
for this medication.
- **patient_consent_required**: The payer requires verbal consent
from the patient before discussing or processing the prior
authorization.
- **more_information_required**: Insufficient information provided
to complete the prior authorization.
- **other**: A problem not listed here was encountered. Check the
`outcome.detail` field for more information.
trigger_message:
type: boolean
title: Trigger Message
description: >-
If True, a message will be added to the prior authorization after
creation. This simulates a follow-up message and will trigger the
prior authorization message webhook.
default: false
type: object
title: PriorAuthMockResultOther
description: Represents a mock result for a prior authorization request.
PriorAuthMockResultNotSubmitted:
properties:
result:
type: string
enum:
- Not Submitted
const: Not Submitted
title: Result
description: >-
The prior authorization request will not be submitted. For example,
when the eligibility check is enabled and the check returns as
error.
default: Not Submitted
detail_code:
allOf:
- $ref: '#/components/schemas/PriorAuthOutcomeNotSubmittedDetail'
description: >-
A code indicating the reason for the prior auth outcome. The
possible values are:
- **eligibility_check_error**: Indicates eligibility check
encountered an error. Error details will be surfaced in the
`eligibility_check_response` field. This status will not happen if
`ndp_submission.ignore_eligibility_check_error` was set to True for
the PA request.
- **eligibility_check_government_plan**: Indicates that the
eligibility check revealed the patient has only government insurance
plan(s). The `eligibility_check_response` field will contain the
successful eligibility check response. This status will not happen
if `ndp_submission.submit_pa_with_eligibility_check_government_plan`
was set to True for the PA request.
- **prescription_message_not_found**: Indicates the provided
prescription message ID does not correspond to a prescription. This
can happen if the eScript received to the NDP could not be converted
into a valid prescription.
- **more_information_required**: Indicates that additional
information is required before this request can be submitted. The
request was not submitted and should be resubmitted with the
additional details.
- **formulary_alternative_required**: Indicates that the patient
needs to try a formulary alternative before the PA can be approved.
The request was not submitted and should instead be submitted for
the formulary alternative outlined in the outcome message.
- **benefit_verification_no_medication_coverage**: Indicates that a
triggered benefit verification determined the prescribed medication
is not covered by the patient's plan.
- **benefit_verification_only_alternative_medication_covered**:
Indicates that a triggered benefit verification determined the
prescribed medication is not covered, but an alternative medication
specified in the request is covered.
- **benefit_verification_pa_not_required**: Indicates that a
triggered benefit verification determined the prescribed medication
is covered and does not require prior authorization.
- **pbm_excluded**: Indicates that the eligibility check revealed
only an excluded PBM payer and the PA was not submitted. The
`eligibility_check_response` field will contain the successful
eligibility check response.
- **payer_not_supported**: Indicates that the eligibility check
revealed the patient's health plan is not supported. Currently,
Kaiser health plans are not supported. The
`eligibility_check_response` field will contain the successful
eligibility check response.
type: object
title: PriorAuthMockResultNotSubmitted
description: >-
Represents a mock result where the prior authorization was NOT submitted
because the eligibility check either encountered an error or revealed
the
patient has a government plan.
Priority:
type: integer
enum:
- 0
- 1
- 2
- 3
title: Priority
description: |-
Represents a priority level. Lower numbers are higher priority.
- CRITICAL: 0
- HIGH: 1
- MEDIUM: 2
- LOW: 3
TriggerBenefitVerificationConfig:
properties:
enabled:
type: boolean
title: Enabled
description: Whether to trigger a benefit verification when creating this PA.
additional_medications:
items:
$ref: '#/components/schemas/TriggerBenefitVerificationMedication'
type: array
title: Additional Medications
description: >-
Additional medications to check coverage for alongside the
prescribed medication.
type: object
required:
- enabled
title: TriggerBenefitVerificationConfig
CreatePriorAuthResponseError:
properties:
title:
type: string
title: Title
description: A brief title summarizing the error.
description:
type: string
title: Description
description: >-
A detailed message explaining the error. These messages may be
unique to the specific prior authorization request.
code:
allOf:
- $ref: '#/components/schemas/PriorAuthErrorCode'
description: >-
A specific code identifying the error. While we'll aim to ensure
that the occurence of these errors is minimal, it's likely they will
occur. To prevent delays to patient care, we generally recommend
that you implement a strategy of falling back to your existing
process for handling a prior authorization if you encounter one of
these errors. The Develop Health team will then work with you in
parallel to fix the issue. The following codes are currently
possible:
- **unsupported_patient**: This means that the patient you submitted
the prior authorization for is not currently supported. We're
rapidly increasing our PBM and payer coverage, so we'll be reducing
the occurrence of these over time.
- **unsupported_drug**: The drug you submitted is not yet supported
for prior authorization.
- **insurance_card_member_id_ocr_failure**: We were unable to
extract the member ID from the insurance card image provided and no
discrete values were provided.
- **insurance_content_invalid_rx_bin**: The Rx BIN provided in the
insurance content is invalid. This should be a 6 digit number.
- **prescription_message_not_found**: The prescription_message_id
provided does not correspond to any known prescription.
- **prescription_message_already_linked**: The
prescription_message_id provided is already linked to a prior
authorization request that is in progress or has already been
completed as approved. The existing PA request must be cancelled
before submitting a new request for the same prescription.
- **provider_not_authorized**: The NPI provided is not authorized to
submit requests. To enable prior authorization requests for this
provider, please complete the provider authorization process.
- **evidence_file_download_failed**: The evidence file could not be
downloaded from the provided URL.
- **invalid_qle_resubmission**: Quantity limit exception
resubmissions are only allowed when the previous prior authorization
was approved or was not required.
- **previous_pa_request_in_progress**: The previous prior
authorization request referenced in resubmission_info is still in
progress. It must be completed or cancelled before a new
resubmission can be created.
- **other**: An unexpected error occurred during the prior
authorization process.
choices:
- - unsupported_patient
- unsupported_patient
- - unsupported_drug
- unsupported_drug
- - insurance_card_member_id_ocr_failure
- insurance_card_member_id_ocr_failure
- - insurance_content_invalid_rx_bin
- insurance_content_invalid_rx_bin
- - prescription_message_not_found
- prescription_message_not_found
- - prescription_message_already_linked
- prescription_message_already_linked
- - provider_not_authorized
- provider_not_authorized
- - evidence_file_download_failed
- evidence_file_download_failed
- - invalid_qle_resubmission
- invalid_qle_resubmission
- - previous_pa_request_in_progress
- previous_pa_request_in_progress
- - other
- other
existing_prior_auth_request_id:
type: string
title: Existing Prior Auth Request Id
description: >-
Identifier of an existing prior authorization request related to
this error.
type: object
required:
- title
- code
title: CreatePriorAuthResponseError
CreatePriorAuthResponseData:
properties:
id:
type: string
minLength: 1
title: Id
description: The unique identifier for the created prior authorization request.
type: object
required:
- id
title: CreatePriorAuthResponseData
description: >-
Represents the data contained in the response for a create prior
authorization request.
ValidationError:
properties:
loc:
items:
anyOf:
- type: string
- type: integer
type: array
title: Location
msg:
type: string
title: Message
type:
type: string
title: Error Type
type: object
required:
- loc
- msg
- type
title: ValidationError
Asset:
properties:
file_content:
type: string
minLength: 1
title: File Content
description: >-
The file content, encoded in Base64 format. Currently only PDF files
are supported. This field cannot be used if `file_url` is provided.
file_url:
type: string
maxLength: 2083
minLength: 1
format: uri
title: File Url
description: >-
URL pointing to the file. The file will be downloaded immediately.
This field cannot be used if `file_content` is provided.
type: object
title: Asset
Address:
properties:
street:
type: string
minLength: 1
title: Street
description: Street address of residence.
street_line_2:
type: string
title: Street Line 2
description: Additional street address information.
city:
type: string
minLength: 1
title: City
description: City of residence.
state_province:
type: string
minLength: 1
title: State Province
description: State or province of residence.
zip_postal_code:
type: string
minLength: 1
title: Zip Postal Code
description: ZIP or postal code part of the address.
country:
type: string
minLength: 1
title: Country
description: Country of residence.
type: object
required:
- street
- city
- state_province
- zip_postal_code
- country
title: Address
description: Represents a postal address.
Gender:
type: string
enum:
- male
- female
- other
- not_specified
title: Gender
description: An enumeration.
DoseForm:
type: string
enum:
- aerosol
- bar
- bead
- breadstick
- bulk
- capsule
- catheter
- cement
- cigarette
- cloth
- concentrate
- cone
- cream
- crystal
- culture
- dentifrice
- deposit
- device
- diaphragm
- disc
- douche
- dressing
- drops
- elixir
- emulsion
- enema
- extract
- film
- food
- foam
- gel
- generator
- globule
- graft
- gum
- implant
- infusion
- inhalant
- inhalation
- inhaler
- injectable
- injection
- insert
- irrigant
- irrigation
- jelly
- kit
- lens
- liner
- liniment
- lipstick
- liquid
- lollipop
- lotion
- lozenge
- miscellaneous
- mouthwash
- mucilage
- oil
- ointment
- packing
- paste
- pastille
- patch
- pellet
- pill
- plaster
- poultice
- powder
- resin
- ring
- rinse
- rod
- salve
- shampoo
- soap
- sol
- solution
- sponge
- spray
- stick
- strip
- suppository
- suspension
- suture
- swab
- syrup
- tablet
- tampon
- tape
- tea
- test
- tincture
- troche
- vaginal_suppository
- vaginal_tablet
- wafer
- wash
- wax
title: DoseForm
description: An enumeration.
RouteOfAdministration:
type: string
enum:
- auricular (otic)
- otic
- buccal
- conjunctival
- cutaneous
- dental
- electro-osmosis
- endocervical
- endosinusial
- endotracheal
- enteral
- epidural
- extra-amniotic
- extracorporeal
- hemodialysis
- infiltration
- interstitial
- intra-abdominal
- intra-amniotic
- intra-arterial
- intra-articular
- intrabiliary
- intrabronchial
- intrabursal
- intracameral
- intracanalicular
- intracardiac
- intracartilaginous
- intracaudal
- intracavernous
- intracavitary
- intracerebral
- intracisternal
- intracorneal
- intracoronal, dental
- intracoronary
- intracorporus cavernosum
- intracranial
- intradermal
- intradiscal
- intraductal
- intraduodenal
- intradural
- intraepicardial
- intraepidermal
- intraesophageal
- intragastric
- intragingival
- intrahepatic
- intraileal
- intralesional
- intralingual
- intraluminal
- intralymphatic
- intramammary
- intramedullary
- intrameningeal
- intramuscular
- intranodal
- intraocular
- intraomentum
- intraovarian
- intrapericardial
- intraperitoneal
- intrapleural
- intraprostatic
- intrapulmonary
- intraruminal
- intrasinal
- intraspinal
- intrasynovial
- intratendinous
- intratesticular
- intrathecal
- intrathoracic
- intratubular
- intratumor
- intratympanic
- intrauterine
- intravascular
- intravenous
- intraventricular
- intravesical
- intravitreal
- iontophoresis
- irrigation
- laryngeal
- nasal
- nasogastric
- not applicable
- occlusive dressing technique
- ophthalmic
- oral
- oropharyngeal
- parenteral
- percutaneous
- periarticular
- peridural
- perineural
- periodontal
- rectal
- respiratory (inhalation)
- inhalation
- retrobulbar
- soft tissue
- subarachnoid
- subconjunctival
- subcutaneous
- subgingival
- sublingual
- submucosal
- subretinal
- suprachoroidal
- topical
- transdermal
- transendocardial
- transmucosal
- transplacental
- transtracheal
- transtympanic
- ureteral
- urethral
- vaginal
title: RouteOfAdministration
description: >-
See:
https://www.fda.gov/industry/structured-product-labeling-resources/route-administration
OptionalAddress:
properties:
street:
type: string
title: Street
description: Street address of residence.
street_line_2:
type: string
title: Street Line 2
description: Additional street address information.
city:
type: string
title: City
description: City of residence.
state_province:
type: string
title: State Province
description: State or province of residence.
zip_postal_code:
type: string
title: Zip Postal Code
description: ZIP or postal code part of the address.
country:
type: string
title: Country
description: Country of residence.
type: object
title: OptionalAddress
description: >-
Represents a postal address with optional fields.
Used for cases where address information may not be complete at creation
time.
Question:
properties:
answer:
type: string
minLength: 1
title: Answer
description: The answer to the question.
choices:
items:
type: string
type: array
title: Choices
description: >-
Optional list of choices for the question. If provided, the answer
must be one of the choices. It's important to include this list of
choices for any multiple choice question. This allows our AI to know
what a user has effectively said 'no' to by picking another option.
I.e. for a question 'Do you have any of the following conditions:
Diabetes, Heart Disease, Cancer, None of the above' if the user
answers 'None of the above' we can infer that they don't have any of
those conditions. Without the choices list we would have no way of
knowing that.
question:
type: string
minLength: 1
title: Question
description: The question to be answered.
type: object
required:
- answer
- question
title: Question
description: Represents a single question, as part of a questionnaire.
AppealLetter:
properties:
asset:
allOf:
- $ref: '#/components/schemas/Asset'
title: Asset
description: File asset containing the appeal letter.
title:
type: string
minLength: 1
title: Title
description: Title of the appeal letter
date_created:
type: string
format: date-time
title: Date Created
description: The date and time when the appeal letter was created.
type: object
required:
- asset
- title
- date_created
title: AppealLetter
description: An appeal letter file to include with the appeal submission.
PriorAuthOutcomeApprovalDetail:
type: string
enum:
- prior_auth_not_required
- approval
- existing_approval
title: PriorAuthOutcomeApprovalDetail
description: An enumeration.
PrescriptionTransferErrorCode:
type: string
enum:
- pharmacy_does_not_exist
- pharmacy_permanently_closed
- pharmacy_unable_to_accept_transfer
- pharmacy_unable_to_fill_prescription
- prescription_transfer_not_received
- transfer_timed_out
- other
title: PrescriptionTransferErrorCode
description: An enumeration.
PriorAuthOutcomeDenialDetail:
type: string
enum:
- formulary_alternative_preferred
- medical_necessity_criteria_not_met
- plan_exclusion
- step_therapy_criteria_not_met
- existing_denial
- coverage_limits_exceeded
- prior_weight_loss_program_required
- unknown
title: PriorAuthOutcomeDenialDetail
description: An enumeration.
PriorAuthOutcomeOtherDetailPublic:
type: string
enum:
- coverage_inactive
- coverage_not_yet_started
- no_pharmacy_benefits
- payer_unable_to_locate_member
- npi_taxonomy_ineligible
- payer_reported_invalid_patient_info
- duplicate_request
- prior_auth_not_required
- patient_consent_required
- more_information_required
- other
title: PriorAuthOutcomeOtherDetailPublic
description: >-
Public version of PriorAuthOutcomeOtherDetail. This is used in the API
response.
PriorAuthOutcomeNotSubmittedDetail:
type: string
enum:
- eligibility_check_error
- eligibility_check_government_plan
- prescription_message_not_found
- more_information_required
- formulary_alternative_required
- benefit_verification_no_medication_coverage
- benefit_verification_only_alternative_medication_covered
- benefit_verification_pa_not_required
- pbm_excluded
- payer_not_supported
title: PriorAuthOutcomeNotSubmittedDetail
description: An enumeration.
TriggerBenefitVerificationMedication:
properties:
ndc:
type: string
title: Ndc
description: The NDC of the additional medication to check coverage for.
quantity:
type: integer
title: Quantity
description: The quantity of the medication to check coverage for.
type: object
required:
- ndc
- quantity
title: TriggerBenefitVerificationMedication
PriorAuthErrorCode:
type: string
enum:
- unsupported_patient
- unsupported_drug
- insurance_card_member_id_ocr_failure
- insurance_content_invalid_rx_bin
- prescription_message_not_found
- prescription_message_already_linked
- provider_not_authorized
- evidence_file_download_failed
- invalid_qle_resubmission
- previous_pa_request_in_progress
- other
title: PriorAuthErrorCode
description: Public version of PriorAuthErrorCode. This is used in the API response.
securitySchemes:
FronteggJWTAuthentication:
type: http
scheme: bearer
bearerFormat: JWT
description: >-
Bearer authentication header of the form `Bearer `, where
`` is your auth token.
````