Prior authorization, explained for the people who run it.
X12 278 code reference
UM01 request categories, UM02 certification types, service type codes, HCR action codes, and common AAA rejection reasons — 92 entries and growing.
CMS-0057-F by payer type
What the rule requires — and when — for Medicare Advantage, Medicaid MCO, CHIP, QHP (FFE).
Prior-auth glossary
74 terms from PAS and CRD to pend, gold carding, and enforcement discretion — each with a citation-ready definition.
Latest articles
All articles →Health-IT engineers & architects
X12 278 vs FHIR PAS: Why You Need Both Rails (and Will for Years)
The X12 278 is still the HIPAA-mandated prior auth transaction; FHIR PAS is what CMS-0057-F pushes payers toward. Enforcement discretion bridges them — but only end-to-end. Here's the architectural reality of running both.
UM operations leaders
What UM Ops Teams Actually Need From an SLA Dashboard (and Rarely Get)
CMS-0057-F's 72-hour and 7-day clocks turned turnaround time into a compliance boundary. Most UM reporting still looks backward. Here's the working spec for an SLA dashboard that prevents breaches instead of documenting them.
Health-IT engineers & architects
Testing the Dual Stack: Cross-Rail Lifecycle Cases Your QA Plan Is Missing
Most prior authorization test plans validate the 278 rail and the FHIR PAS rail separately. The bugs live in between — auths that start on one rail and get extended, cancelled, or queried on the other. A concrete cross-rail test catalog.
Compliance & program leads
State UM Statutes vs Federal Floors: Building the Strictest-Rule Engine
CMS-0057-F's turnaround clocks are floors, not ceilings. State prior authorization laws — Texas gold-carding, Washington's one-day expedited clock — can be stricter, and the strictest applicable rule wins. How to encode that as data and govern it.
UM operations & intake leadership
Reading a 278 Rejection: A Field Guide to AAA Codes for Intake Teams
AAA segments in a 278 response mean the request couldn't be processed — not that care was denied. How to read AAA01, AAA03, and AAA04, and how to triage rejections before they quietly burn the decision clock.
Compliance & regulatory program leads
The QHP Carve-Out: Why Marketplace Plans Got Different CMS-0057 Rules
QHP issuers on the FFEs are impacted payers under CMS-0057-F — but the 72-hour/7-day decision timeframes exclude them. Here's the regulatory reasoning, what marketplace compliance teams still owe, and how multi-line payers should handle the split.