Prior Authorization
The CMS Interoperability & Prior Authorization Final Rule (CMS-0057-F) workflow, at the point of care: CRD — is prior auth required? · DTR — what documentation the payer needs · PAS — assemble & submit the request.
Carelon MSAG + local CRD table. For Carelon (PBHS) the "is prior auth required?" answer comes
from the official CBH Master Service Authorization Grid — per benefit package (fund code); pick the
member's package for the exact requirement. Other payers use a seed rules table until a live Da Vinci
CRD endpoint is connected. The PAS step shapes the request payload but does not transmit —
wire it to the payer's Prior Authorization API to submit.
Is prior authorization required?
CRDEnter a payer + code to check.
Documentation the payer will require
DTRPaste the clinical note — the DTR questionnaire is answered from the documentation. Anything missing is what you'd need to supply to substantiate medical necessity.
Check a code, then paste the note.
Authorization tracking
RenewalOnce an authorization is granted, track its span. Carelon (PBHS) requires the continued-stay/concurrent request before the last authorized day; this flags the 30/14/7-day reminders and the determination turnaround.
Enter the authorization span to track renewals.
Prior authorization request
PASDraft
Submitted
Pending
Approved / Denied
Assemble the request to preview the PAS payload.