1up Electronic Prior Authorization

Transform prior authorization with real-time, FHIR®-powered automation.

Benefits

Prior Authorization Without the Pain

Your prior authorization process is painful, but it doesn’t have to be. With 1up Electronic Prior Authorization, you can replace manual processes and fragmented systems with an intelligent, FHIR-native workflow that works across EHRs, provider portals, UM systems, and all lines of business.

Built for scale, adaptability, and regulatory confidence, 1up Electronic Prior Authorization simplifies how requests are submitted, reviewed, and returned — without disrupting the systems you already use.

Smarter, Faster Decisions

Accelerates prior authorization by streamlining intake, instantly surfacing requirements, and quickly returning decisions.

Lower Administrative Burden

Reduces Utilization Management workload by replacing labor-intensive intake channels and follow-up with structured digital submissions and efficient review workflows.

Better Provider Experience

Gives providers a clear, consistent submission process — across EHRs, provider portals, and beyond — that minimizes administrative effort.

Improved Member Access to Care

Ensures members receive timely care through faster reviews, fewer delays, and more predictability across service lines.

1upHealth’s unparalleled FHIR API expertise was key in navigating the first interoperability regulations, and we’re grateful to have their support as we address new requirements for prior authorization and patient data access.

John Budaj, Vice President of Information Technology, Fallon Health

Compliance

CMS Compliance Made Easy

Meet CMS-0057-F requirements with FHIR-based automation, without managing the technical complexity yourself.

Electronic Prior Authorization FHIR APIs

FHIR-based CRD, DTR, and PAS APIs with secure OAuth2 authentication for automated, real-time prior authorization. Supports FHIR to X12 conversion.

Electronic Prior Authorization Usage Reporting

Pre-built dashboards that track decision turnaround, approval patterns, and API usage to support CMS-mandated reporting.

FEATURES

Value Driven Beyond Compliance

1up Electronic Prior Authorization does more than meet regulatory requirements. It enables automation, connectivity, and real-time intelligence across your ecosystem.

• Faster decisions, fewer delays
• Intelligent Routing Engine: Routes requests to the correct UM system automatically using configurable rules. Supports complex, multi-UM environments.
• Fewer resubmissions, faster decisions
• CRD Server: Surfaces coverage criteria directly in the provider’s workflow (EHR, portal, etc.) to prevent missing documentation and slowdowns.
• Quicker adoption, cleaner intake
• DTR Questionnaire: Provides a static FHIR questionnaire when UM vendors lack one, ensuring complete submissions.
• Reliable speed at scale
• Optimized Performance: Delivers sub-five-second response times through a fast, scalable, enterprise-grade architecture.
• Faster provider adoption
• Provider Network: Allows providers to connect once via a one-to-many network, eliminating point-to-point payer integrations.
• Simplified provider setup
• Provider Registration & Onboarding: Enables providers to onboard and obtain OAuth2 credentials via a secure, self-service portal.
• Cleaner Cross-State Routing
• BCBSA Interoperability Hub Connectivity: Routes requests for Blues plans to the Association when home-and-host plans differ.
• Faster outreach, better support
• Real-Time Event Streams: Provides a real-time stream of FHIR and non-FHIR events for status, analytics, and care management workflows.

How It Works

An intelligent, real-time electronic prior authorization workflow built around the tools providers already use, including EHRs and provider portals.

Order Creation

Provider initiates an order directly in their EHR or provider portal. No new systems or workflow changes required.

Policy Check

The 1up API checks whether prior authorization is required based on payer rules.

Surface Documentation Requirements

If required, coverage details and questionnaires are returned to the provider.

Submission

Providers complete documentation and submit the request electronically.

Routing & Review

1up routes the request to the correct UM system and returns updates as they occur.

Decision Tracking

The provider’s EHR or portal displays the status and final decision, along with reason codes.

Demo

See 1up Electronic Prior Authorization in Action

Explore interactive product tours and see exactly how 1up Electronic Prior Authorization handles submissions, routing, and decisions from start to finish.

FAQs

How does 1up Electronic Prior Authorization integrate with existing workflows?

1up sits between EHRs and UM systems, acting as a secure routing and orchestration layer. We use OAuth2, SMART on FHIR, and mTLS to connect with EHRs, provider portals, and other submission tools, while supporting FHIR APIs and custom mappings for UM systems.

Can 1up work with our existing prior authorization or UM solution?

Yes. 1up’s modular design supports selective adoption of CRD, DTR, or PAS and integrates with your current systems.

Do providers need to integrate directly with 1up?

No. Providers self-register via the 1up Dev Portal and can begin testing immediately, reducing your onboarding burden.

What if a request requires manual review?

1up supports asynchronous workflows using FHIR Subscriptions in PAS, delivering decisions automatically when available.

How are routing rules and prior authorization requirements managed?

Routing and prior authorization rules are submitted as structured spreadsheets, ingested into the 1up Electronic Prior Authorization Metastore, and applied in real time.

What reporting is included?

We capture all CMS-mandated metrics – approval/denial rates, time-to-decision, appeals outcomes – and present them in dashboards and exports for public reporting.