Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot

Da Vinci - Prior Authorization Support, HL7 International - Financial Management Work Group - CI build for vesion 0.1.0). This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Artifact List

Artifact Packages

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

Operations

Operations to be supported by EMRs and payor systems conforming to this implementation guide

  •  Submit Claim PAS constraints on the generic Claim/$submit operation

Extensions

Extensions defined as part of this implementation guide

  •  Institutional Encounter Extension used on a Claim resource to identify information about a hospital admission.
  •  Certification Type Extension used on a Claim resource to identify the type of the pre-authorization that is being requested.
  •  Requested Service Detail Extension used on a Claim resource to more specific information about a service being requested.
  •  Information Changed Indicator Extension used on a Claim resource to identify if information about a service item has changed.
  •  Item Cancelled Indicator Extension used on a Claim resource to identify if a claim item has been cancelled.
  •  Authorization Issue Date Extension used on a ClaimResponse resource to identify when the authorization was issued.
  •  Item Reference Identifier Extension used on a ClaimResponse resource to provide identifiers for this specific item.
  •  Review Action Code Extension used on a ClaimResponse resource to identify the outcome of the authorization request.
  •  Review Action Reason Code Extension used on a ClaimResponse resource to identify the reason for the authorization (or not).
  •  Event Authorized Date/Period Extension used on a ClaimResponse resource to identify a specific date or period when the event has been authorized for.
  •  Item Pre-Authorization Period Extension used on a ClaimResponse resource to identify the period over which the specific item has been authorized.
  •  Report Transmission Mode Extension used on a DocumentReference resource to identify the mode by which the document is transferred.
  •  Patient Hospitalization Status Extension used on an Encounter resource to identify the status of the patient while the patient was hospitalized for the encounter.
  •  Patient Nursing Home Residential Status Extension used on an Encounter resource to identify whether a patient was a nursing home resident.
  •  EPSDT Involvement Indicator Extension used on a ServiceRequest resource to identify the the requested service is based on Early and Periodic Screening for the Diagnosis and Treatment of Children (EPSDT).
  •  Nursing Home Level of Care Extension used on a ServiceRequest resource to identify the level of care provided by a nursing home to the patient.
  •  Calendar Pattern Code Extension used on a Timing datatype to identify a specific calendar delivery pattern.
  •  Delivery Pattern Code Extension used on a Timing datatype to identify the time delivery pattern for services.

Profiles

Profiles to be supported by EMRs and payor systems conforming to this implementation guide

  •  PAS Bundle PAS constraints on Bundle resource ensuring that a claim/claim update/claim response resource is present and that non-supported elements are not.
  •  PAS Claim PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request
  •  PAS Claim Update PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request
  •  PAS Claim Response PAS constraints on Claim resource mandating support for elements relevant to the response of a prior authorization request
  •  PAS Requestor Organization PAS constraints on Organization resource mandating support for elements relevant to the requestor of a prior authorization request
  •  PAS UMO Organization PAS constraints on Organization resource mandating support for elements relevant to the Utilization Management Organization of a prior authorization request
  •  PAS Care Team Organization PAS constraints on Organization resource mandating support for elements relevant to an Organization forming part of a Care Team for a prior authorization request
  •  PAS Requestor Practitioner PAS constraints on Practitioner resource mandating support for elements relevant to the requestor of a prior authorization request
  •  PAS Care Team Practitioner PAS constraints on Practitioner resource mandating support for elements relevant to an Practitioner forming part of a Care Team for a prior authorization request
  •  PAS Requestor PractitionerRole PAS constraints on PractitionerRole resource mandating support for elements relevant to the requestor of a prior authorization request
  •  PAS CareTeam PractitionerRole PAS constraints on PractitionerRole resource mandating support for elements relevant to the care team and performers of a prior authorization request
  •  PAS Coverage PAS constraints on Coverage resource mandating support for elements relevant to the insurance of a prior authorization request
  •  PAS Subscriber Patient PAS constraints on Patient resource mandating support for elements relevant to the subscriber of a prior authorization request
  •  PAS Beneficiary Patient PAS constraints on Patient resource mandating support for elements relevant to the beneficiary of a prior authorization request
  •  PAS Condition PAS constraints on Condition resource mandating support for elements relevant to the diagnosis of a prior authorization request
  •  PAS Location PAS constraints on Location resource mandating support for elements relevant to the of a prior authorization request
  •  PAS Timing PAS constraints on Timing datatype for elements relevant to a prior authorization request
  •  PAS Encounter PAS constraints on Encounter resource for elements relevant to a institutional claim for a prior authorization request
  •  PAS DocumentReference PAS constraints on DocumentReference resource for additional information sent with a prior authorization request
  •  PAS ServiceRequest PAS constraints on ServiceRequest resource for service level event information sent with a prior authorization request
  •  PAS CommunicationRequest PAS constraints on CommunicationRequest resource for requesting additional information to be sent for a prior authorization request

Terminology

Value Sets and/or code systems defined as part of this implementation guide

  •  PAS Claim Supporting Information Type Claim Supporting Information Type Code System
  •  PAS Claim Supporting Information Type Value Set Claim Supporting Information Type Value Set
  •  PAS Information Change Mode Information Change Mode Code System
  •  PAS Information Change Mode Value Set Information Change Mode Value Set

Example(s)

Example(s) showing the use of the PAS profiles

  •  PA Referral Request example Example of a Prior Authorization request for a referral
  •  PA Referral Response example Example of a Prior Authorization response for a referral
  •  PA Home Health Care Request example Example of a Prior Authorization request for home health care
  •  PA Home Health Care Updated Request example Example of a Prior Authorization for an update to a home health care request
  •  PA Home Health Care Differential Request example Example of a Prior Authorization for a differential request