Coverage Requirements Discovery API Getting Started
The Coverage Requirement Discovery (CRD) API advises if prior authorization is needed for a treatment to be covered by insurance.
The API determines whether prior authorization is required and if it retrieves coverage details for a requested service using FHIR-based Clinical Decision Support (CDS) Hooks. The API evaluates member, provider, diagnosis, and service information to return real-time guidance, including prior authorization requirements, coverage insights, and links to initiate documentation workflows through Documentation Templates & Rules(DTR).
In Prior Auth Burden Reduction initiative, the Coverage Requirement Check API enables seamless integration with the Centers for Medicare & Medicaid Services (CMS) Interoperability framework, supporting Prior Authorization workflows through CDS Hooks. This API follows the HL7 FHIR DaVinci CRD Implementation Guide standards and facilitates:
- Coverage verification
- Prior Authorization (PA) requirement checks
- DTR link generation for questionnaire completion
Endpoint
/crd/{hook_id}— retrieves the list of available CDS services from the discovery endpoint based on the CDS Hooks specification.
Updated about 2 hours ago