Prior Authorization Item Webform

PA FHIR Translation Tool

Create a rule

Define the criteria of a new Prior Authorization item

Rule Information

Rule Type Rule Name Rule Description

Conditions

Condition 1 Condition: Condition Value: Condition 2 Condition: Condition Value: Condition 3 Condition Key: Condition Value: Condition 4 New Condition: New Condition Value:

Service Request Codes

Service Request Codes Coding System:

Code:

Display:

Text:

Coverage Requirements

Define the coverage requirements of the Prior Authorization item

Coverage PA Rule
Rule Information
Covered?
PA Needed *
Documentation Needed *
Documentation Purpose *
Info Needed *

Required Assessment(s)

Required Evidence

Required Documentation

Questionaire(s)

Questionaire (URL) *

Contact

PA FHIR Translation Tool

Create a rule

Coverage Requirements

Coverage PA Rule