Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

Other IG Artifacts

Page standards status: Informative

Previous Page - Artifacts

Other Implementation Guides

An important objective in the HL7 Da Vinci Accelerator Project is to avoid unnecessary profile proliferation and to leverage common processes. To this end the PDex IG leverages the profiles, extensions and operations incorporated into other Implementation Guides.

Implementation Guides

PDex references the following Implementation Guides:

• US Core 3.1.1
• US Core 6.1.0
• Da Vinci Health Record Exchange (HRex) 1.0.0
• Da Vinci Member Attribution (ATR) 2.1.0
• Da Vinci Prior Authorization Support (PAS) 2.1.0
• FAST National Directory (NDH)

Note: The FAST National Directory (NDH) IG has yet to be published. To enable PDex to leverage the profiles and extensions in the NDH IG the required Profiles, Extensions, Value Sets and Code Systems have been copied into PDex. Once the NDH IG is published it is intended that the PDex IG would remove the NDH content in a future PDex STU update and reference the FAST NDH IG directly.

Profiles

The following profiles are referenced in this IG:

US Core

• US Core 3.1.1 Profiles
• US Core 6.1.0 Profiles
• US Core 7.0.0 Profiles

Health Record Exchange (HRex)

• HRex Patient Demographics
• HRex Coverage Profile
• HRex Consent Profile
• HRex Parameters Member Match Request Profile
• HRex Parameters Member Match Response Profile

Da Vinci Member Attribution (ATR)

• ATRGroup

Operations

The following operations are referenced:

Health Record Exchange (HRex)

• HRex Member Match Operation

Da Vinci Member Attribution (ATR)

NOTE: exportType parameter SHALL be populated with a value for all PDex implementations of the $Davinci-data-export-operation. ^§pdex-118 i.e., Provider Access API and Payer-to-Payer Bulk API.

• $Davinci-data-export-operation

IG/package dependencies

The following dependencies are used in production of this guide:

Cross version analysis

This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (hl7.fhir.us.davinci-pdex.r4) and R4B (hl7.fhir.us.davinci-pdex.r4b) are available.

IP Statements

This publication includes IP covered under the following statements.

• All X12 products are subject to this IP policy, including published and draft works.X12 is the only organization authorized to grant permission for use of X12 products. Users of all X12 products should make sure that they understand the permissible uses, as well as the limitations on such usage, as outlined below.Additional IP information can be found here Send an email to ip@x12.org to request permission to reproduce X12 IP. Include your name, organization, title, address, city, state, zip, email, a detailed description of the Submitted Artifact, including the underlying or cited X12 Product, and a detailed description of the intended audience and planned distribution method for the Artifact.Additional information on X12 licensing program can be found here To purchase code list subscriptions call (425) 562-2245 or email admin@wpc-edi.com.
  Show Usage
  • X12 Claim Adjustment Reason Codes: PdexPriorAuthorization and X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
• All X12 work products are copyrighted. Any use of any X12 work product must be compliant with US Copyright laws and X12 Intellectual Property policies.Please see https://x12.org/products/licensing-program
  Show Usage
  • X12 Service Type Codes: ExplanationOfBenefit/PDexPriorAuth1, PdexPriorAuthorization and PriorAuthServiceTypeCodes
• CMS maintains HIPPS. There are no known constraints on the use of HIPPS.
  Show Usage
  • Health Insurance Prospective Payment System (HIPPS): ExplanationOfBenefit/PDexPriorAuth1, PDexPAInstitutionalProcedureCodes, PDexPAInstitutionalProcedureCodesVS and PdexPriorAuthorization
• Current Procedural Terminology (CPT) is copyright 2020 American Medical Association. All rights reserved
  Show Usage
  • Current Procedural Terminology (CPT®): PDexPAInstitutionalProcedureCodes, PDexPAInstitutionalProcedureCodesVS and PdexPriorAuthorization
• ISO maintains the copyright on the country codes, and controls its use carefully. For further details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
  Show Usage
  • ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code: AssociatedServers, AttestationProvisionTypeValueSet... Show 106 more, AttestationStatusValueSet, BulkMemberMatch, ContactPointAvailableTime, DaVinciPayerDataExchange, DispenseRefill, DynamicRegistration, EndpointAccessControlMechanism, EndpointPayloadTypeCS, EndpointPayloadTypeVS, EndpointRank, EndpointUsecase, ExplanationOfBenefit_Identifier, ExplanationOfBenefit_Patient, ExplanationOfBenefit_ServiceDate, ExplanationOfBenefit_Type, ExplanationOfBenefit_Use, FDANationalDrugCode, FhirIg, Group_Code, IdentifierStatus, LevelOfServiceCode, MatchCoverage, MatchParameters, MemberOptOut, MemberProviderTreatmentRelationship, MembersOptedOut, MtlsBundle, MtlsEndpoint, MtlsObjectCodeCS, MtlsObjectTypeVS, MtlsOrganization, MtlsSignedObject, OptOutDetails, OptOutReason, OptOutReasonCodeSystem, OptOutReasonValueSet, OptOutScopeCodeSystem, OptOutScopeValueSet, OrgTypeCS, OrgTypeVS, PDexAdjudication, PDexAdjudicationCategoryDiscriminator, PDexAdjudicationDiscriminator, PDexConsentAction, PDexConsentApiPurposeCS, PDexConsentApiPurposeVS, PDexConsentProviderAccess, PDexConsentProvisionType, PDexGroupCharacteristicValueReference, PDexIdentifierType, PDexMemberCharacteristicCode, PDexMemberMatchGroup, PDexMemberNoMatchGroup, PDexMultiMemberMatchRequestParameters, PDexMultiMemberMatchResponseParameters, PDexMultiMemberMatchResultVS, PDexPAInstitutionalProcedureCodes, PDexPAInstitutionalProcedureCodesVS, PDexPayerAdjudicationStatus, PDexPayerBenefitPaymentStatus, PDexProviderGroup, PDexProviderSharingConsent, PDexServerCapabilityStatement61, PDexSupportingInfoType, PDexSupportingInfoTypeCS, PdexDevice, PdexMedicationDispense, PdexMedicationDispensePatient, PdexMedicationDispenseStatus, PdexMemberAttributionCS, PdexMultiMemberMatchResultCS, PdexPayerAccessServerCapabilityStatement, PdexPriorAuthorization, PdexProviderAccessServerCapabilityStatement, PdexServerCapabilityStatement, PriorAuthServiceTypeCodes, PriorAuthorizationAmounts, PriorAuthorizationUtilization, PriorAuthorizationValueCodes, Provenance, ProvenanceAgentRoleType, ProvenanceAgentType, ProvenancePayerDataSource, ProvenancePayerSourceFormat, ProvenanceSourceFrom, ProviderAccessUseCase, ProviderMemberMatch, ProviderMemberMatchGroup, ProviderMemberNoMatchGroup, ProviderMultiMemberMatchRequestParameters, ProviderMultiMemberMatchResponseParameters, ProviderTreatmentAttestation, ReviewAction, ReviewActionCode, SecureExchangeArtifacts, TreatmentRelationshipDetails, TreatmentRelationshipTypeCodeSystem, TreatmentRelationshipTypeValueSet, TrustFramework, TrustFrameworkTypeCS, TrustFrameworkTypeVS, TrustProfileCS, VerificationStatus, WhenAdjudicated, X12278ReviewDecisionReasonCode and X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
• These codes are excerpted from ASTM Standard, E1762-95(2013) - Standard Guide for Electronic Authentication of Health Care Information, Copyright by ASTM International, 100 Barr Harbor Drive, West Conshohocken, PA 19428. Copies of this standard are available through the ASTM Web Site at www.astm.org.
  Show Usage
  • Signature Type Codes: Bundle/example-mtls-endpoint-bundle
• This CodeSystem is not copyrighted.
  Show Usage
  • C4BB Adjudication Code System: PDexAdjudication, PDexAdjudicationCategoryDiscriminator and PdexPriorAuthorization
  • PDex Adjudication Discriminator: PDexAdjudicationCategoryDiscriminator and PdexPriorAuthorization
  • PDex Identifier Type: Group/example-pdex-treatment-relationship-group, Group/example-provider-consent-constrained-group, Group/example-provider-matched-group, Group/example-provider-nomatch-group and Group/member-opt-out-group-001
  • PDex Payer Adjudication Status: PDexPayerBenefitPaymentStatus
  • PDex Supporting Info Type: PDexSupportingInfoType
• This is an example set based on ASTM Standard, E1762-95 (2013) HL7 RoleClass OID 2.16.840.1.113883.5.110, HL7 Role Code 2.16.840.1.113883.5.111, HL7 ParticipationType OID: 2.16.840.1.113883.5.90, HL7 ParticipationFunction codes at OID: 2.16.840.1.113883.5.88, and HL7 Security and Privacy Domain Analysis Model roles classes.
  Show Usage
  • Contract Signer Type Codes: Bundle/1000000-1, Bundle/1000000-2, Bundle/1000000-3 and Provenance/1000017
• This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
  Show Usage
  • LOINC: Consent/provider-treatment-attestation-1, Consent/treatment-attestation-ex1... Show 7 more, Consent/treatment-attestation-ex2, DocumentReference/123456, DocumentReference/provider-attestation-doc-1, DocumentReference/treatment-attestation-form-001, DocumentReference/treatment-attestation-form-002, Parameters/provider-member-match-request-001 and ProviderTreatmentAttestation
• This material contains content that is copyright of SNOMED International. Implementers of these specifications must have the appropriate SNOMED CT Affiliate license - for more information contact https://www.snomed.org/get-snomed or info@snomed.org.
  Show Usage
  • SNOMED Clinical Terms® (SNOMED CT®): Bundle/1000000-1, Bundle/1000000-2... Show 7 more, Bundle/1000000-3, Bundle/3000003, Device/543210, Encounter/6, Encounter/7, Encounter/8 and PdexDevice
• This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
  Show Usage
  • Adjudication Value Codes: ExplanationOfBenefit/PDexPriorAuth1, PDexAdjudication and PdexPriorAuthorization
  • Claim Type Codes: ExplanationOfBenefit/PDexPriorAuth1
  • Condition Category Codes: Bundle/3000003
  • Condition Clinical Status Codes: Bundle/3000003
  • ConditionVerificationStatus: Bundle/3000003
  • Consent Action Codes: Consent/consent-2, Consent/consent-permit-1, Consent/no-consent-1, PDexProviderSharingConsent and Parameters/payer-multi-member-match-in
  • Consent Category Codes: ProviderTreatmentAttestation
  • Consent PolicyRule Codes: Consent/consent-permit-1, Consent/no-consent-1 and PDexProviderSharingConsent
  • Consent Scope Codes: Consent/consent-2, Consent/consent-permit-1... Show 8 more, Consent/no-consent-1, Consent/provider-treatment-attestation-1, Consent/treatment-attestation-ex1, Consent/treatment-attestation-ex2, PDexProviderSharingConsent, Parameters/payer-multi-member-match-in, Parameters/provider-member-match-request-001 and ProviderTreatmentAttestation
  • Coverage Class Codes: Coverage/CoverageMatchExample1, Coverage/CoverageMatchExample2... Show 4 more, Coverage/coverage-2, Matched Members, Parameters/payer-multi-member-match-in and Parameters/provider-member-match-request-001
  • DataAbsentReason: Bundle/example-mtls-endpoint-bundle, MtlsEndpoint... Show 4 more, PDexPAInstitutionalProcedureCodes, PDexPAInstitutionalProcedureCodesVS, Payer-Payer Exchange and PdexPriorAuthorization
  • Endpoint Connection Type: Bundle/example-mtls-endpoint-bundle, MtlsEndpoint and Payer-Payer Exchange
  • Example Diagnosis Type Codes: ExplanationOfBenefit/PDexPriorAuth1
  • Example Related Claim Relationship Codes: ExplanationOfBenefit/PDexPriorAuth1
  • Funds Reservation Codes: ExplanationOfBenefit/PDexPriorAuth1
  • Organization type: DiamondOnyxHealth, Example Provider Organization and Second Example Provider Organization
  • Process Priority Codes: ExplanationOfBenefit/PDexPriorAuth1 and PdexPriorAuthorization
  • Professional Credential Status: IdentifierStatus
  • Provenance participant type: Bundle/1000000-1, Bundle/1000000-2... Show 15 more, Bundle/1000000-3, Bundle/3000003, Consent/consent-2, Consent/consent-permit-1, Consent/no-consent-1, PDexProviderSharingConsent, Parameters/payer-multi-member-match-in, Provenance, Provenance/1000002, Provenance/1000003, Provenance/1000004, Provenance/1000005, Provenance/1000006, Provenance/1000101 and ProvenanceAgentType
  • SubscriberPolicyholder Relationship Codes: Coverage/883210, Coverage/Coverage1... Show 6 more, Coverage/CoverageMatchExample1, Coverage/CoverageMatchExample2, Coverage/coverage-2, Coverage/coverage-link-2, Parameters/payer-multi-member-match-in and Parameters/provider-member-match-request-001
  • identifierType: Bundle/1000000-1, Bundle/1000000-2... Show 28 more, Bundle/1000000-3, Coverage/883210, Coverage/Coverage1, Coverage/coverage-2, Coverage/coverage-link-2, Group/example-pdex-member-consent-constraint-group, Group/example-pdex-member-no-match-group, Matched Members, Parameters/payer-multi-member-match-in, Parameters/payer-multi-member-match-out, Parameters/provider-member-match-request-001, Patient/1, Patient/1-2, Patient/100, Patient/1001, Patient/2002, Patient/PatientMemberMatchExample1, Patient/PatientMemberMatchExample2, Patient/patient-2, Patient/patient-prov-001, Patient/patient-prov-002, Patient/payer-member-001, Patient/payer-member-002, Payer 1, Payer 2, Practitioner/4, Provider 1 and Provider 2
  • ActCode: Bundle/1000000-1, Bundle/1000000-2... Show 20 more, Bundle/1000000-3, Bundle/2000002, Bundle/3000002, Consent/consent-2, Consent/consent-permit-1, Consent/no-consent-1, Consent/provider-treatment-attestation-1, Consent/treatment-attestation-ex1, Consent/treatment-attestation-ex2, Coverage/CoverageMatchExample1, Coverage/CoverageMatchExample2, DocumentReference/provider-attestation-doc-1, Encounter/6, Encounter/7, Encounter/8, MedicationDispense/1000001, PDexProviderSharingConsent, Parameters/payer-multi-member-match-in, Parameters/provider-member-match-request-001 and PdexMedicationDispense
  • ActReason: Consent/provider-treatment-attestation-1, Consent/treatment-attestation-ex1... Show 4 more, Consent/treatment-attestation-ex2, Parameters/provider-member-match-request-001, Provenance/1000101 and ProviderTreatmentAttestation
  • DataOperation: Provenance/1000101
  • NullFlavor: Bundle/1000000-1, Bundle/1000000-2... Show 4 more, Bundle/1000000-3, Patient/1, Patient/1-2 and Patient/100
  • ParticipationType: Consent/consent-2, Consent/provider-treatment-attestation-1... Show 4 more, Consent/treatment-attestation-ex1, Consent/treatment-attestation-ex2, Parameters/payer-multi-member-match-in and Parameters/provider-member-match-request-001
  • RoleClass: Consent/provider-treatment-attestation-1
• Used by permission of HL7 International, all rights reserved Creative Commons License
  Show Usage
  • US Core DocumentReferences Category Codes: DocumentReference/123456
  • US Core Provenance Participant Type Extension Codes: Bundle/1000000-1, Bundle/1000000-2... Show 8 more, Bundle/1000000-3, Bundle/3000002, Provenance, Provenance/1000001, Provenance/1000016, Provenance/1000017, Provenance/1000101 and ProvenanceAgentType
  • Endpoint Payload Types Code System: EndpointPayloadTypeVS
  • mTLS Object Type Code: MtlsObjectTypeVS, MtlsSignedObject and Payer-Payer Exchange
  • Organization Type: Acme of CT and OrgTypeVS
  • PDex Provider Access API Attribution Code System: Attributed List of Health Plan Members for Practitioner 1122334455., Group/example-pdex-treatment-relationship-group... Show 8 more, MemberOptOut, MemberProviderTreatmentRelationship, PDexMemberMatchGroup, PDexMemberNoMatchGroup, PDexMultiMemberMatchResultVS, PDexProviderGroup, ProviderMemberMatchGroup and ProviderMemberNoMatchGroup
  • PDex Multi-Member Match Result Code System: Group/example-pdex-member-consent-constraint-group, Group/example-pdex-member-no-match-group... Show 16 more, Group/example-pdex-treatment-relationship-group, Group/example-provider-consent-constrained-group, Group/example-provider-matched-group, Group/example-provider-nomatch-group, Group/member-opt-out-group-001, Matched Members, MemberOptOut, MemberProviderTreatmentRelationship, PDexMemberMatchGroup, PDexMemberNoMatchGroup, PDexMultiMemberMatchResultVS, PDexProviderGroup, Parameters/payer-multi-member-match-out, Parameters/provider-member-match-response-001, ProviderMemberMatchGroup and ProviderMemberNoMatchGroup
  • Prior Authorization Values: ExplanationOfBenefit/PDexPriorAuth1, PdexPriorAuthorization and PriorAuthorizationAmounts
  • Provenance Roles: Provenance and ProvenanceAgentType
  • Provenance Payer Data Source Format: Bundle/1000000-1, Bundle/1000000-2... Show 13 more, Bundle/1000000-3, Bundle/3000002, Bundle/3000003, Provenance, Provenance/1000001, Provenance/1000002, Provenance/1000003, Provenance/1000004, Provenance/1000005, Provenance/1000006, Provenance/1000016, ProvenancePayerSourceFormat and ProvenanceSourceFrom
  • Trust FrameworkType Code System: TrustFramework and TrustFrameworkTypeVS
  • Opt-Out Reason Code System: Group/member-opt-out-group-001, OptOutReason and OptOutReasonValueSet
  • Opt-Out Scope Code System: Group/member-opt-out-group-001, MemberOptOut, OptOutScopeValueSet and Parameters/provider-member-match-response-001
  • PDex Consent API Purpose: Consent/consent-permit-1, Consent/no-consent-1, PDexConsentApiPurposeVS and PDexProviderSharingConsent
  • Treatment Relationship Type Code System: TreatmentRelationshipTypeValueSet

[Next Page - Downloads]