CareParse PayerLab

CareParse PayerLab is a payer-side prior authorization sandbox for Medicare and Medicare Advantage workflows.

This repository records the required interoperability standards, provides a reproducible fetch pipeline for machine-readable artifacts, and hosts a local payer-side PAS simulator that product and AI-agent workflows can test against before production payer integrations.

Current Scope

• Maintain a standards manifest in packages/lock.yaml.
• Fetch required standards and payer implementation-guide artifacts into generated/.
• Verify artifact versions, checksums, extraction, and expected resource files.
• Simulate payer-side CRD, DTR, PAS submission, and PAS status inquiry with deterministic fixtures.
• Document the standards layer and why the repository does not vendor complete implementation guide websites.

Non-Goals

This phase does not implement the product agent, user interfaces, knowledge graph logic, full prior authorization decision engines, ASC workflows, Medicare policy rules, denial scoring, appeals, benchmarks, X12 conversion, or live payer integrations.

Usage

Fetch standards artifacts:

./scripts/fetch-specs.sh

Verify the local standards cache:

./scripts/verify-specs.sh

The generated artifacts are local build outputs. The committed source of truth is the manifest, fetch script, verification script, and documentation.

The active external conformance target is recorded in:

packages/conformance-targets.json

Run the payer simulator:

PAYERLAB_PORT=8080 ./mvnw exec:java

Run the portable Docker stack:

docker compose up --build

The simulator exposes a payer-side CRD -> DTR -> PAS path:

GET  http://localhost:8080/cds-services
POST http://localhost:8080/cds-services/payerlab-crd-prior-auth
GET  http://localhost:8080/fhir/Questionnaire/payerlab-dental-orthodontics
POST http://localhost:8080/fhir/QuestionnaireResponse/$submit
POST http://localhost:8080/fhir/Claim/$submit
POST http://localhost:8080/fhir/Claim/$inquire

Run the five-minute workflow smoke test against a running simulator:

PAYERLAB_BASE_URL=http://localhost:8080 ./scripts/smoke-workflow.sh

Run the SMART Backend Services auth smoke test:

PAYERLAB_BASE_URL=http://localhost:8080 ./scripts/smoke-smart-backend-auth.sh >/dev/null

The PAS status inquiry endpoint is:

POST http://localhost:8080/fhir/Claim/$inquire
Content-Type: application/fhir+json

Smoke test the running stack:

curl -sS \
  -H 'Content-Type: application/fhir+json' \
  --data @fixtures/payer/requests/approved-inquiry.bundle.json \
  http://localhost:8080/fhir/Claim/\$inquire

Run the dental prior authorization status demo:

curl -sS \
  -H 'Content-Type: application/fhir+json' \
  --data @fixtures/payer/requests/dental-approved-inquiry.bundle.json \
  http://localhost:8080/fhir/Claim/\$inquire

Run the Java test suite:

./mvnw test

Docs

• docs/standards.md
• docs/payer-simulator.md
• docs/conformance.md
• docs/why-not-vendor-igs.md