{"uid":"cap_Ah1PNc3leMPR1MgaaeKGU","slug":"automatedrcm-prior-authorization-check-pat-9aecae8f","name":"AutomatedRCM Prior Authorization Check (PAT)","description":"Prior-authorization determination for a CPT/HCPCS code + US payer. Rules engine covering UHC, Aetna, Cigna, Florida Blue, Humana, Medicare, Medicare Advantage across 13 high-volume codes (imaging, surgery, sleep, cardiology, pain mgmt, wound care, specialty drugs). Returns requirement, criteria, documentation checklist, payer portal + turnaround. Codes outside the ruleset return coverage:false with guidance (no charge avoidance — check GET / for the covered list first). (AutomatedRCM agent: PAT)","url":"https://x402.getautomatedrcm.com/pa-check","method":"POST","headers":{},"bodySchema":{"type":"object","properties":{"cpt":{"type":"string","description":"CPT/HCPCS procedure code, e.g. 29881"},"icd10":{"type":"string","description":"Optional ICD-10 diagnosis code"},"payer":{"type":"string","description":"US payer: UHC, AETNA, CIGNA, FLBLUE, HUMANA, MEDICARE, MEDICARE_ADV"}}},"responseSchema":null,"example":null,"exampleRequest":null,"tags":["x402"],"displayCostAmount":"0.05","displayCostAsset":"USDC","priceDynamic":false,"priceHint":null,"priceStatus":"priced","priceSource":"probe","requiresHandshake":false,"reviewCount":0,"rating":{"score":"0.00","successRate":"0.00","reviews":0,"stars":null,"state":"unrated"},"availabilityStatus":"unknown","priceObserved":null,"sessionDeposit":null,"pricing":{"kind":"static","summary":"$0.05/call","primary":{"kind":"static","protocol":"x402","network":"base","amountUsd":"0.05","per":"call","confidence":"exact"},"accepted":[{"kind":"static","protocol":"x402","network":"base","amountUsd":"0.05","per":"call","confidence":"exact"}]},"paymentMethods":[{"uid":"pm_M6r7o3V2Qo5sXx4c4yuFd","protocol":"x402","methodType":"crypto","chain":"base","mode":"charge","costAmount":"0.05","costPer":"request","priority":0,"asset":"0x833589fCD6eDb6E08f4c7C32D4f71b54bdA02913","unit":"request","depositMicros":null,"planRef":null}],"brandName":null,"brandSlug":null,"brandBaseUrl":null,"brandDocsUrl":null,"whatItDoes":"Determines whether a CPT/HCPCS procedure code requires prior authorization from a specific US payer, returning requirements, clinical criteria, documentation checklist, payer portal link, and turnaround time.","exampleAgentPrompt":"Does CPT code 27447 (total knee replacement) require prior authorization with UHC, and if so, what documentation and clinical criteria do I need to submit?","exampleUseCases":[{"title":"Pre-scheduling imaging prior auth check","prompt":"Before we schedule this patient for an MRI of the knee — CPT 70553 — can you check whether Aetna requires prior authorization and what clinical documentation we'd need to get it approved?"},{"title":"Specialty drug PA requirements lookup","prompt":"Our patient needs a specialty drug infusion, HCPCS J0135, and their payer is Humana. Do we need prior authorization, and if so what are the criteria and how long will it take?"},{"title":"Surgery authorization eligibility verification","prompt":"We have a patient scheduled for a rotator cuff repair, CPT 29827, and they're on Medicare Advantage. What are the prior auth requirements, and where do we submit the request?"}],"resultDescription":"Returns a structured response indicating whether prior authorization is required (coverage flag), the specific clinical criteria the payer applies, a checklist of required documentation, the payer's submission portal URL, and expected turnaround time. For CPT/HCPCS codes outside the supported ruleset, returns coverage:false with guidance to check the covered code list.","failureModes":["CPT/HCPCS code outside the 13-code ruleset — returns coverage:false with guidance but no PA details","Unsupported payer name — request may fail or return no match","Malformed CPT code string — validation error","ICD-10 code mismatch may affect criteria precision if provided incorrectly","Network or payment failure if x402 micropayment not processed"],"whenToPreferThis":"Use this endpoint when you need a fast, rule-based prior authorization determination for a specific CPT or HCPCS code against one of the seven major US payers (UHC, Aetna, Cigna, Florida Blue, Humana, Medicare, Medicare Advantage). It is purpose-built for the 13 highest-volume clinical categories (imaging, surgery, sleep, cardiology, pain management, wound care, specialty drugs) and returns actionable output including documentation checklists and portal links. Prefer this over general payer portal lookups when you need structured, machine-readable PA requirements that can be fed directly into an RCM workflow.","instructions":null,"reviewSummary":null,"reviewSummaryHighlights":null,"reviewSummaryConcerns":null,"reviewSummaryGeneratedAt":null,"activationCount":0,"lastUsedAt":null,"lastSuccessfullyRanAt":null,"lastHealthCheckAt":"2026-09-13T18:33:36.098Z","isFirstParty":false}