API Overview

PriorAuthKit turns clinician-provided clinical information into structured prior authorization packets — checklists, evidence mapping, denial normalization, and appeal scaffolding. It does not automate payer portals, scrape websites, or make clinical decisions. All outputs require clinician review before submission.

Endpoints

1. Packet Builder — `POST /v1/pa/packet/build`

Build a complete prior auth packet with cover letter, clinical rationale, and therapy history.

Request

{
  "patient_context": { "age_years": 45, "contains_phi": false, "no_store": true },
  "request": {
    "therapy_requested": "Humira (adalimumab) 40mg biweekly",
    "indication_as_stated": "Moderate-to-severe rheumatoid arthritis",
    "clinical_summary_as_stated": "Patient has had RA for 3 years. Failed methotrexate 20mg weekly x 6 months (inadequate response). Failed sulfasalazine 1g BID x 4 months (GI intolerance). ESR 42, CRP 3.2. DAS28 score 5.1.",
    "prior_therapies": [
      { "name": "Methotrexate", "dose": "20mg weekly", "duration": "6 months", "outcome": "failed" },
      { "name": "Sulfasalazine", "dose": "1g BID", "duration": "4 months", "outcome": "intolerant", "notes": "GI intolerance" }
    ],
    "allergies_or_contraindications": ["Sulfa allergy"],
    "labs_or_imaging_as_stated": "ESR 42, CRP 3.2, RF positive, Anti-CCP positive",
    "benefit_of_therapy_as_stated": "Biologic therapy indicated after failure of 2 conventional DMARDs"
  },
  "payer_template": "biologic",
  "codes": { "icd10": ["M05.79"], "cpt": ["96372"] },
  "options": { "output": "both", "redact_phi": true, "missing_field_strict": true }
}

Response

{
  "disclaimer": "Documentation assistance only. Clinician review required before submission.",
  "packet_id": "a1b2c3d4-e5f6-7890-abcd-ef1234567890",
  "packet_json": {
    "checklists": {
      "present": [
        "indication_as_stated",
        "therapy_requested",
        "prior_therapies",
        "clinical_summary_as_stated",
        "allergies_or_contraindications",
        "labs_or_imaging_as_stated",
        "benefit_of_therapy_as_stated"
      ],
      "missing": [],
      "recommended_additions": ["Consider adding specific joint involvement details"]
    },
    "payer_requirements": [
      "Diagnosis of moderate-to-severe RA confirmed",
      "Failure of ≥2 conventional DMARDs documented",
      "Contraindications/intolerances documented",
      "Relevant lab work supporting diagnosis"
    ],
    "evidence_map": [
      { "requirement": "Documented diagnosis", "evidence_present": true, "source_field": "indication_as_stated" },
      { "requirement": "Prior therapy failures", "evidence_present": true, "source_field": "prior_therapies" },
      { "requirement": "Lab results supporting diagnosis", "evidence_present": true, "source_field": "labs_or_imaging_as_stated" }
    ],
    "submission_sections": {
      "cover_letter": "To Whom It May Concern, ...",
      "clinical_rationale": "This 45-year-old patient carries a diagnosis of moderate-to-severe rheumatoid arthritis ...",
      "therapy_history": "1. Methotrexate 20mg weekly x 6 months — failed (inadequate response)\n2. Sulfasalazine 1g BID x 4 months — intolerant (GI intolerance)"
    }
  },
  "packet_md": "# Prior Authorization Request\n\n## Cover Letter\nTo Whom It May Concern, ...\n\n## Clinical Rationale\n...",
  "request_id": "req_abc123"
}

2. Checklist — `POST /v1/pa/checklist`

Fast completeness check — returns what's present, what's missing, and what's recommended.

Request

{
  "request": {
    "therapy_requested": "Ozempic 1mg weekly",
    "indication_as_stated": "Type 2 diabetes",
    "clinical_summary_as_stated": "HbA1c 8.9%. Failed metformin 2000mg daily x 12 months."
  },
  "payer_template": "specialty_rx"
}

Response

{
  "present": [
    "therapy_requested",
    "indication_as_stated",
    "clinical_summary_as_stated"
  ],
  "missing": [
    "prior_therapies (structured)",
    "labs_or_imaging_as_stated",
    "codes.icd10"
  ],
  "recommended_additions": [
    "Add structured prior_therapies array with dose, duration, and outcome",
    "Include recent HbA1c as a lab value",
    "Add ICD-10 code E11.65 for Type 2 diabetes with hyperglycemia",
    "Document allergies or contraindications if applicable"
  ],
  "request_id": "req_def456"
}

3. Evidence Mapper — `POST /v1/pa/evidence/map`

Map clinical note text against payer requirements with snippet citations and confidence scores. Never fabricates evidence.

Request

{
  "requirements": [
    "Documented diagnosis of moderate-to-severe RA",
    "Failure of at least 2 conventional DMARDs",
    "Recent inflammatory markers (ESR or CRP)",
    "Tuberculosis screening prior to biologic initiation"
  ],
  "note_text": "Assessment: 45yo female with moderate-to-severe rheumatoid arthritis, DAS28 5.1. Failed methotrexate 20mg weekly x 6mo (inadequate response) and sulfasalazine 1g BID x 4mo (GI intolerance). Labs: ESR 42, CRP 3.2, RF positive, Anti-CCP positive. Plan: Initiate adalimumab 40mg SC biweekly.",
  "options": { "redact_phi": true, "no_store": true }
}

Response

{
  "mapped": [
    {
      "requirement": "Documented diagnosis of moderate-to-severe RA",
      "evidence_bullets": [
        "\"moderate-to-severe rheumatoid arthritis, DAS28 5.1\"",
        "\"RF positive, Anti-CCP positive\""
      ],
      "confidence": 0.97
    },
    {
      "requirement": "Failure of at least 2 conventional DMARDs",
      "evidence_bullets": [
        "\"Failed methotrexate 20mg weekly x 6mo (inadequate response)\"",
        "\"sulfasalazine 1g BID x 4mo (GI intolerance)\""
      ],
      "confidence": 0.95
    },
    {
      "requirement": "Recent inflammatory markers (ESR or CRP)",
      "evidence_bullets": [
        "\"ESR 42, CRP 3.2\""
      ],
      "confidence": 0.93
    },
    {
      "requirement": "Tuberculosis screening prior to biologic initiation",
      "evidence_bullets": [],
      "confidence": 0.0
    }
  ],
  "gaps": [
    "Tuberculosis screening prior to biologic initiation — no evidence found in note"
  ]
}

4. Denial Normalizer — `POST /v1/pa/denial/normalize`

Parse freeform denial text into structured reason codes, summary, and recommended next steps.

Request

{
  "denial_text": "The request for Humira (adalimumab) has been denied. The documentation submitted does not demonstrate medical necessity. Specifically, there is insufficient evidence that the patient has tried and failed an adequate trial of a preferred biologic agent (e.g., Enbrel, Rinvoq) prior to requesting a non-preferred agent. Additionally, recent TB screening results were not included. Reference: Policy BIO-2024-RA, Section 4.2."
}

Response

{
  "reason_codes": [
    "STEP_THERAPY_NOT_MET",
    "MISSING_DOCUMENTATION",
    "MEDICAL_NECESSITY_NOT_ESTABLISHED"
  ],
  "summary": "Denied for failure to demonstrate step therapy through a preferred biologic and missing TB screening documentation. Policy reference: BIO-2024-RA, Section 4.2.",
  "recommended_next_steps": [
    "Document clinical rationale for why preferred agents are not appropriate (e.g., contraindication, prior failure, formulary exception)",
    "Obtain and submit TB screening results (QuantiFERON-TB Gold or PPD)",
    "Request formulary exception with supporting literature if preferred agents are contraindicated",
    "File peer-to-peer review to discuss medical necessity with payer medical director"
  ]
}

5. Appeal Draft Scaffold — `POST /v1/pa/appeal/draft`

Generate an appeal letter draft with attachments checklist and talking points. Not legal advice.

Request

{
  "denial_summary": "Denied for failure to try preferred biologic (step therapy) and missing TB screening.",
  "packet_json": {
    "checklists": {
      "present": ["indication_as_stated", "therapy_requested", "prior_therapies"],
      "missing": ["tb_screening"]
    },
    "payer_requirements": [
      "Trial of preferred biologic",
      "TB screening prior to initiation"
    ]
  },
  "additional_notes_as_stated": "Patient has documented sulfa allergy which contraindicates sulfasalazine. Enbrel was considered but patient has history of demyelinating disease (MS), which is a contraindication per FDA label.",
  "tone": "formal"
}

Response

{
  "disclaimer": "This is a documentation scaffold only. It is not legal or medical advice. Clinician review and signature required before submission.",
  "appeal_letter_md": "# Appeal of Prior Authorization Denial\n\n**Date:** [INSERT DATE]\n**Re:** [PATIENT IDENTIFIER] — Humira (adalimumab) 40mg\n**Denial Reference:** [INSERT REFERENCE]\n\nDear Medical Director,\n\nI am writing to appeal the denial of prior authorization for adalimumab ...\n\n## Clinical Rationale for Non-Preferred Agent\n\nThe patient has a documented history of demyelinating disease (multiple sclerosis), which represents an FDA-labeled contraindication to etanercept (Enbrel) ...\n\n## Addressing Missing Documentation\n\nTB screening (QuantiFERON-TB Gold) has now been completed. Results: [INSERT RESULTS]. Please find attached.\n\n## Conclusion\n\nGiven the documented contraindications to preferred agents and the clinical evidence supporting adalimumab, we respectfully request reconsideration ...\n\nSincerely,\n[CLINICIAN NAME, CREDENTIALS]",
  "attachments_checklist": [
    "Updated TB screening results (QuantiFERON-TB Gold)",
    "Neurology consultation note documenting MS diagnosis",
    "FDA label for Enbrel highlighting demyelinating disease contraindication",
    "Original prior auth packet with clinical summary",
    "Peer-reviewed literature supporting adalimumab in patients with MS comorbidity"
  ],
  "talking_points": [
    "Enbrel is contraindicated per FDA label due to patient's documented demyelinating disease (MS)",
    "Patient has failed 2 conventional DMARDs (methotrexate, sulfasalazine)",
    "Sulfa allergy further limits treatment options",
    "TB screening has been completed and results are attached",
    "Request peer-to-peer review if denial is upheld"
  ]
}

6. Store Packet — `POST /v1/packets/store`

Opt-in retention of redacted packets. Off by default.

Request

{
  "packet_json": {
    "checklists": { "present": ["indication_as_stated", "therapy_requested"], "missing": [] },
    "payer_requirements": ["Diagnosis confirmed", "Prior therapy documented"]
  },
  "packet_md": "# Prior Authorization Request\n\n...",
  "options": { "retention": true, "expires_days": 30 }
}

Response (201 Created)

{
  "packet_id": "f7e6d5c4-b3a2-1098-7654-321fedcba987",
  "stored": true,
  "expires_at": "2025-06-12T00:00:00Z",
  "message": "Packet stored (redacted). Expires in 30 days."
}

7. List Packets — `GET /v1/packets?limit=10`

Retrieve stored packets for the authenticated subscriber.

Response

{
  "packets": [
    {
      "packet_id": "f7e6d5c4-b3a2-1098-7654-321fedcba987",
      "created_at": "2025-05-13T14:22:00Z",
      "expires_at": "2025-06-12T00:00:00Z",
      "therapy_requested": "Humira 40mg biweekly",
      "indication": "Rheumatoid arthritis"
    }
  ],
  "total": 1,
  "limit": 10
}

8. Get Packet — `GET /v1/packets/{packet_id}`

Retrieve a single stored packet by ID.

Response

{
  "packet_id": "f7e6d5c4-b3a2-1098-7654-321fedcba987",
  "created_at": "2025-05-13T14:22:00Z",
  "expires_at": "2025-06-12T00:00:00Z",
  "packet_json": { "..." },
  "packet_md": "# Prior Authorization Request\n\n..."
}

9. List Templates — `GET /v1/templates`

Returns available payer templates with their required and optional fields.

Response

{
  "templates": [
    {
      "id": "biologic",
      "name": "Biologic / Biosimilar",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated", "prior_therapies"],
      "optional_fields": ["allergies_or_contraindications", "labs_or_imaging_as_stated", "benefit_of_therapy_as_stated", "codes"]
    },
    {
      "id": "specialty_rx",
      "name": "Specialty Pharmacy",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated"],
      "optional_fields": ["prior_therapies", "labs_or_imaging_as_stated", "codes"]
    },
    {
      "id": "imaging",
      "name": "Advanced Imaging",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated"],
      "optional_fields": ["labs_or_imaging_as_stated", "codes"]
    },
    {
      "id": "pt_ot",
      "name": "Physical / Occupational Therapy",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated"],
      "optional_fields": ["prior_therapies", "codes"]
    },
    {
      "id": "dme",
      "name": "Durable Medical Equipment",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated"],
      "optional_fields": ["labs_or_imaging_as_stated", "codes"]
    },
    {
      "id": "generic",
      "name": "Generic (catch-all)",
      "required_fields": ["therapy_requested", "indication_as_stated", "clinical_summary_as_stated"],
      "optional_fields": ["prior_therapies", "allergies_or_contraindications", "labs_or_imaging_as_stated", "benefit_of_therapy_as_stated", "codes"]
    }
  ]
}

10. Plan Limits — `GET /v1/limits`

Returns the current subscriber's plan limits and usage.

Response

{
  "plan": "Pro",
  "limits": {
    "api_calls_per_month": 10000,
    "rate_limit_per_minute": 600,
    "retention_days": 7
  },
  "usage": {
    "api_calls_this_month": 1247,
    "packets_stored": 3
  },
  "resets_at": "2025-06-01T00:00:00Z"
}

Payer Templates

Use the payer_template field to select a submission template:

generic — catch-all default
biologic — biologics and biosimilars (step therapy focus)
specialty_rx — specialty pharmacy medications
imaging — advanced imaging (MRI, CT, PET)
pt_ot — physical and occupational therapy
dme — durable medical equipment

Safety & Compliance

No portal automation — does not connect to or scrape any payer portal
Clinician review required — every output carries a disclaimer; nothing is auto-submitted
No evidence fabrication — the Evidence Mapper only cites text present in the input
PHI redaction on by default — redact_phi: true is the default for all endpoints
No-store default — packets are not retained unless you explicitly opt in
Not legal or medical advice — appeal scaffolds are documentation aids only

Pricing

Tier	Price	API Calls / mo	Rate Limit	Retention
Free	$0	100	60 req/min	Disabled
Pro	$25/mo	10,000	600 req/min	7 days (redacted)
Ultra	$75/mo	50,000	2,400 req/min	30 days (redacted)
Mega	$150/mo	250,000	6,000 req/min	90 days (redacted)

Support

Contact: priorauthhelper@fastmail.com