Redix CMS-0057-F API Documentation

API reference for the Redix CMS-0057-F Prior Authorization Suite

Overview

The Redix CMS-0057-F Prior Authorization Suite covers the four API areas of the CMS Interoperability and Prior Authorization Final Rule. Built on the proven Redix AnyToAny Conversion Engine, it converts X12 278 and RMap formats to Da Vinci PAS FHIR, with response conversion back to X12 278, and provides demonstration endpoints for the Patient Access, Provider Access and Payer-to-Payer APIs. Production deployment and integration with your systems are scoped per customer.

What's Included

Technical Specifications

Authentication

Authentication is deployment-specific. The demo uses an API key. Production deployments use identity and access infrastructure agreed for the deployment; an API key alone does not establish production PAS security. The public demo key accepts registered Redix samples only; customer-supported, de-identified input requires a scoped evaluation key.

X-API-Key: demo-key-12345

Demo Authentication

For testing and evaluation with the public demo sandbox:

Quick Start

Patient Access API

Allows patients/members to access their prior authorization history, coverage information, and Explanation of Benefits through FHIR R4 endpoints.

Endpoints

Search Parameters

Provider Access API

The CMS Provider Access API shares patient data with eligible providers. PA submission belongs to the Prior Authorization API; any /api/provider/Claim/$submit route here is a Redix-specific demo route, not the CMS Provider Access requirement.

Endpoints

Payer-to-Payer API

Supports consent-driven data exchange when members switch health plans. Includes bulk FHIR export capabilities.

Endpoints

Da Vinci PAS API

Da Vinci Prior Authorization Support (PAS) operations $submit and $inquire, with X12 278 conversion. The service declares PAS 2.0.1. In the demonstration, authorization decisions are simulated.

Operations

Redix demo endpoints (not Da Vinci PAS operations)

These shortcuts exist in the Redix demonstration only. In the Da Vinci PAS guide, updates and cancellations are sent through $submit: updates use the claim-update profile and cancellations use the infoCancelled extension.

Decision Timeline Requirements

CMS-0057-F sets response timeframes for prior authorization decisions (QHP issuers on the FFEs are excluded). The Redix PAS API carries the request priority and decision fields these timeframes rely on; meeting them depends on the payer’s review process.

PA Status Mapping

ClaimResponse.outcome describes processing, not the clinical authorization decision. Map approval, denial, pending and cancellation using the applicable PAS profile and verified transaction mapping.

X12 278 to FHIR Conversion

Convert X12 278 Prior Authorization transactions to Da Vinci PAS FHIR Bundles using the Redix AnyToAny Conversion Engine.

Endpoints

RMap 278 to FHIR Conversion

RMap (Redix Mapping) is a simplified, human-readable format that converts directly to Da Vinci PAS FHIR Bundles. Ideal for organizations without X12 278 infrastructure.

RMap 278 Format

Illustrative fragment of the format (not an executable example).

# RMap 278 PA Request - Simple, readable format
RMP*RMap_5_278REQ*20251215*0900*278_to_FHIR.map
TR1**PA2025001*20251215*0900**13
UR0*2*ACME HEALTH INS****PI*123456789*1P*1*WILSON*SARAH***34*1234567890
SB0*JOHNSON*ROBERT***19550315*M*MI*XYZ123456789
PE0*SC*I*3*11*B*********Y**27447*1234567890
DX0*BF*M17.11*20251201
SV0*HS*I*1****20251220**I**HC*27447********UN*1
EOF

Record Types

See the included samples/RMAP_278_STRUCTURE.md for complete field-by-field documentation.

FHIR Response to X12 Conversion

Convert Da Vinci PAS FHIR ClaimResponse back to X12 278 Response format for legacy system integration.

Attachment Handling

The Da Vinci PAS specification supports clinical documentation attachments in multiple formats. CMS-0057-F emphasizes electronic clinical data exchange.

Supported Attachment Formats

Provenance Tracking

Redix conversion output includes FHIR Provenance resources that record where each resource came from. CMS-0057-F does not name Provenance as a requirement; access and event audit logging, retention and monitoring are defined for each deployment.

Provenance Includes

• Target - Reference to the resource created/modified
• Recorded - Timestamp of the operation
• Agent - Who performed the action
• Entity - Source data reference (e.g., X12 278 input)
• Activity - Type of operation performed

Error Handling

PAS and FHIR API errors are generally returned as FHIR OperationOutcome resources. On the demo conversion endpoints, authentication, sample-policy and rate-limit responses come from the demo gateway as JSON error messages.

Sample Data

The suite includes pre-loaded sample data for testing:

• 5 Patients
• 3 Practitioners
• 4 Organizations (providers and payers)
• 14 Claims (PA requests)
• 4 ClaimResponses (PA decisions)
• 3 Coverages
• 3 Consents
• 2 ExplanationOfBenefits
• 14 Provenance records

Included Files

Conformance Testing

ONC's Inferno test platform is widely used for FHIR conformance testing. Da Vinci PAS test kits are available, and a deployment can be tested against them. Redix does not currently publish Inferno test results.

Available Test Suites

Running Inferno Tests

1. Go to inferno.healthit.gov/test-kits/davinci-pas/
2. Select "Server Suite" (tests your PAS server)
3. Choose the authentication method supported by your deployment (for example, OAuth through the identity provider agreed for the deployment, or the API key for the demo)
4. Enter your server URL: https://your-server/api/pas
5. Run tests and review results

Validation scope

Evidence currently covers the identified sample conversion outputs; full server conformance and Must Support coverage are not established by those results.

Support