Da Vinci Prior Authorization Support (PAS) FHIR IG
0.1.0 - CI Build

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 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

Artifacts Summary

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

Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems complying with this implementation guide

ClaimInquiryOperation Da Vinci Prior Authorization Support This operation is used to make an inquiry for a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) either as a single Claim resource instance or as a Bundle containing the Claim and other referenced resources, or Bundle containing a batch of Claim resources, either as single Claims resources or Bundle resources, for processing. The only input parameter is the single Claim or Bundle resource and the only output is a single ClaimResponse, Bundle of ClaimResponses or an OperationOutcome resource.
ClaimSubmitOperation Da Vinci Prior Authorization Support This operation is used to submit a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) for adjudication either as a single Claim resource instance or as a Bundle containing the Claim and other referenced resources, or Bundle containing a batch of Claim resources, either as single Claims resources or Bundle resources, for processing. The only input parameter is the single Claim or Bundle resource and the only output is a single ClaimResponse, Bundle of ClaimResponses or an OperationOutcome resource.

Structures: Resource Profiles

These define constraints on FHIR resources that need to be complied with by conformant implementations

PAS Beneficiary Patient A patient who is the beneficiary of an insurance plan.
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 Inquiry PAS constraints on Claim resource when submitting an inquiry for existing authorizations.
PAS Claim Inquiry Response PAS constraints on Claim resource mandating support for elements relevant to the response of an inquiry for details of previous authorizations.
PAS Claim Response PAS constraints on Claim resource mandating support for elements relevant to the response of a prior authorization request
PAS Claim Update PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request
PAS CommunicationRequest PAS constraints on CommunicationRequest resource mandating support for elements relevant to the prior authorization response
PAS Coverage PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request
PAS Device Request PAS constraints on DeviceRequest resource mandating support for elements relevant to the devices being requested on a prior authorization request
PAS Encounter PAS constraints on Encounter resource mandating support for elements relevant to details of a requested instutitional stay on the prior authorization request
PAS Insurer Organization An organization who provides insurance and is the receiver of a prior authorization request.
PAS Medication Request PAS constraints on MedicationRequest resource mandating support for elements relevant to the prescriptions being requested on a prior authorization request
PAS Practitioner PAS constraints on Practitioner resource mandating support for elements relevant to the care team involved in a prior authorization request
PAS Requestor Organization The organization who is making a prior authorization request.
PAS Service Request PAS constraints on ServiceRequest resource mandating support for elements relevant to the generic services being requested on a prior authorization request
PAS Subscriber Patient A patient who is the subscriber of an insurance plan.

Structures: Data Type Profiles

These define constraints on FHIR data types that need to be complied with by conformant implementations

PAS Timing PAS constraints on the Timing datatype used in the various service requests.

Structures: Extension Definitions

These define constraints on FHIR data types that need to be complied with by conformant implementations

AdministrationReferenceNumber A string assigned by the UMO to the original disallowed review outcome associated with this service item.
AuthorizationNumber A string assigned by the UMO to an authorized review outcome associated with this service item.
AuthorizedDate The date/period when the item that is pre-authorizated must be completed.
AuthorizedItemDetail The details for this item of what has been authorized if different from what was requested.
AuthorizedProvider The specific provider who has been authorized to provide this item.
CalendarPattern A code representing the specific days when a service is being requested
CertificationType A code representing the type of certification being requested (UM02)
CommunicatedDiagnosis A code representing the diagnosis that is the subject of the communication
ContentModifier A code representing a modifier of the content being requested
DeliveryPattern A code representing the specific delivery of a service being requested
DiagnosisRecordedDate The date that a diagnosis was recorded. (HIxx-4)
EPSDTIndicator An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.
FollowupAction A code representing what action must occur to resolve this error.
InfoCancelledFlag A flag indicating whether the piece of information was cancelled.
InfoChanged A code indicating how the piece of information has changed.
ItemTraceNumber Uniquely identifies this claim item. (2000F-TRN)
LevelOfServiceCode A code specifying the level of service being requested (UM06)
MilitaryStatus A patient's military status.
NursingHomeLevelOfCare A code specifying the level of care provided by a nursing home facility. (SV120, SV210)
NursingHomeResidentialStatus A code specifying the status of a nursing home resident at the time of service. (SV209)
PatientStatus A code representing the status of the patient when being admitted
PreAuthIssueDate The date when this item's preauthorization was issued.
PreAuthPeriod The date/period when this item's preauthorization is valid.
ProductOrServiceCodeEnd Used to provide the last code in a series of codes for the service being requested.
RequestedService The details of the service being requested.
RevenueUnitRateLimit The limit on the rate per unit of revenue for hospital accomodation. (SV206)
ReviewAction The details of the review action that is necessary for the authorization.
ReviewActionCode The code describing the result of the review.
ServiceItemRequestType A code that identifies the type of service being requested.

Terminology: Value Sets

These define sets of codes used by systems conforming with this implementation guide

AHA NUBC Revenue Codes
PASInformationChangeMode The mode by which a piece of information has changed.
PASSupportingInfoType Types of supporting information for a Prior Authorization Claim.

Terminology: Code Systems

These define new code systems used by systems conforming with this implementation guide

AHA NUBC Revenue Codes These codes are used to convey specific accomodation, ancillary service or unique billing calculations or arrangements. They are listed within the UB-04 Data Specifications Manual and maintained by the National Uniform Billing Committee (NUBC).
PASInformationChangeMode The mode by which a piece of information has changed.
PASSupportingInfoType Types of supporting information for a Prior Authorization Claim.