Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-snapshot - STU 2.2 - Public Review
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-snapshot - STU 2.2 - Public Review
Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-snapshot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions
| Page standards status: Trial-use | Maturity Level: 4 |
{
"resourceType" : "Requirements",
"id" : "fromNarrative",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: Requirements fromNarrative</b></p><a name=\"fromNarrative\"> </a><a name=\"hcfromNarrative\"> </a><p>These requirements apply to the following actors: </p><ul><li><a href=\"ActorDefinition-client.html\">PAS Client</a></li><li><a href=\"ActorDefinition-payer.html\">PAS Payer</a></li></ul><table class=\"grid\"><tr><td><b><a name=\"1\"> </a></b>1</td><td>SHALL</td><td><div><p>spec-77:A subscription-based mechanism SHALL be used by the client to be informed of updates to the authorization.</p>\n</div></td></tr><tr><td><b><a name=\"2\"> </a></b>2</td><td>SHALL</td><td><div><p>spec-77:A subscription-based mechanism SHALL be used by the client to be informed of updates to the authorization.</p>\n</div></td></tr><tr><td><b><a name=\"3\"> </a></b>3</td><td>SHALL</td><td><div><p>spec-33:Each item returned on the PAS ClaimResponse SHALL echo the same item.sequence as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.</p>\n</div></td></tr><tr><td><b><a name=\"4\"> </a></b>4</td><td>SHALL</td><td><div><p>spec-33:Each item returned on the PAS ClaimResponse SHALL echo the same item.sequence as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.</p>\n</div></td></tr><tr><td><b><a name=\"ainfo-1\"> </a></b>Payers MAY request additional information in a number of ways</td><td>MAY</td><td><div><p>A payer <strong>MAY</strong> request additional information from the provider to support a prior authorization request by responding to the X12 278 Request with an X12 278 Response that includes any of the following:</p>\n<ol>\n<li>One or more codes in the PWK01 element</li>\n<li>One or more of the approved LOINC codes Attachments – LOINC in the HI segment</li>\n<li>A single 102089-0 LOINC code in the HI segment to request information via a payer’s specific questionnaire.</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"ainfo-2\"> </a></b>ainfo-2</td><td>SHALL</td><td><div><p>When a single LOINC code is used, the TRN at the X12 278 header or line level associated with the 102089-0 LOINC code <strong>SHALL</strong> be the DTR context ID used to retrieve the appropriate questionnaire.</p>\n</div></td></tr><tr><td><b><a name=\"ainfo-3\"> </a></b>ainfo-3</td><td>SHALL</td><td><div><p>The <a href=\"StructureDefinition-profile-task.html\">PAS task profile</a> <strong>SHALL</strong> be used to convey PAS X12 278 Response information to CDex.</p>\n</div></td></tr><tr><td><b><a name=\"ainfo-4\"> </a></b>ainfo-4</td><td>SHOULD</td><td><div><p>All of the additional information request codes <strong>SHOULD</strong> be used as input to a CDex task.</p>\n</div></td></tr><tr><td><b><a name=\"ainfo-5\"> </a></b>ainfo-5</td><td>SHALL</td><td><div><p>When the LOINC code 102089-0 is present, the associated TRNs <strong>SHALL</strong> also be exchange as Task.input.</p>\n</div></td></tr><tr><td><b><a name=\"ainfo-6\"> </a></b>ainfo-6</td><td>SHALL</td><td><div><p>A separate task <strong>SHALL</strong> be created for each of the above attachment request types (PWK01, LOINC, questionnaire).</p>\n</div></td></tr><tr><td><b><a name=\"conf-1\"> </a></b>conf-1</td><td>SHALL</td><td><div><p>Payers <strong>SHALL</strong> have a distinct endpoint for each different supported version (which are not inter-version compatible) of the PAS specification.</p>\n</div></td></tr><tr><td><b><a name=\"conf-2\"> </a></b>conf-2</td><td>SHALL</td><td><div><p>If a payer supports endpoint discovery, they <strong>SHALL</strong> have at most a single endpoint for each combination of version of the specification and coverage (e.g., Medicare, Medicaid, or commercial) they provide coverage under.</p>\n</div></td></tr><tr><td><b><a name=\"conf-3\"> </a></b>conf-3</td><td>SHALL</td><td><div><p>If a payer does not support endpoint discovery, they <strong>SHALL</strong> expose only one PAS endpoint of each supported version capable of handling all coverages.</p>\n</div></td></tr><tr><td><b><a name=\"conf-4\"> </a></b>conf-4</td><td>SHALL</td><td><div><p>PA Intermediary Systems <strong>SHALL</strong> be capable of processing all data elements that are marked as Must Support on the Claim Request and Claim Inquiry.</p>\n</div></td></tr><tr><td><b><a name=\"conf-5\"> </a></b>conf-5</td><td/><td><div><p>They <strong>SHALL NOT</strong> generate an error or cause the application to fail due the presence of any data element marked as Must Support.</p>\n</div></td></tr><tr><td><b><a name=\"conf-6\"> </a></b>conf-6</td><td>SHALL</td><td><div><p>PA Intermediary Systems <strong>SHALL</strong> be capable of returning resource instances containing any of the data elements that are marked as Must Support on the Claim Response and the Claim Inquiry Response.</p>\n</div></td></tr><tr><td><b><a name=\"conf-7\"> </a></b>conf-7</td><td>SHALL</td><td><div><p>PA Client Systems <strong>SHALL</strong> be capable of receiving all data elements that are marked as Must Support on the Claim Response and the Claim Inquiry Response.</p>\n</div></td></tr><tr><td><b><a name=\"conf-8\"> </a></b>conf-8</td><td/><td><div><p>They <strong>SHALL NOT</strong> generate an error or cause the application to fail when receiving any data element that is marked as Must Support.</p>\n</div></td></tr><tr><td><b><a name=\"conf-9\"> </a></b>conf-9</td><td>SHOULD-NOT</td><td><div><p>PA Client Systems <strong>SHOULD NOT</strong> send any data elements that are not marked as Must Support.</p>\n</div></td></tr><tr><td><b><a name=\"conf-10\"> </a></b>conf-10</td><td>MAY</td><td><div><p>If these data elements are included in a Claim Request or Claim Inquiry, the receiving PA Intermediary System <strong>MAY</strong> ignore those elements.</p>\n</div></td></tr><tr><td><b><a name=\"conf-11\"> </a></b>conf-11</td><td/><td><div><p>When processing prior auth requests and additional data submissions, PAS services <strong>SHALL NOT</strong> depend on or set expectations for the inclusion of resource instances not compliant with profiles defined in this guide, CRD, DTR, HRex, or US Core.</p>\n</div></td></tr><tr><td><b><a name=\"conf-12\"> </a></b>conf-12</td><td/><td><div><p>Similarly, they <strong>SHALL NOT</strong> depend on or set expectations for the inclusion of any data elements not marked as mandatory (min cardinality >= 1) or mustSupport in those profiles.</p>\n</div></td></tr><tr><td><b><a name=\"conf-13\"> </a></b>conf-13</td><td>MAY</td><td><div><p>If the proposed change is adopted and published in the PAS continuous integration build or the CI build of one of its dependencies (e.g. US Core), implementations <strong>MAY</strong>, by mutual agreement, pre-adopt the use of those additional profiles and/or mustSupport data elements and not be considered in violation of #1 above.</p>\n</div></td></tr><tr><td><b><a name=\"conf-14\"> </a></b>conf-14</td><td/><td><div><ol start=\"2\">\n<li>Where cardinality and other constraints present in profiles allow data elements to be omitted, PAS compliant systems <strong>SHALL NOT</strong> treat the omission of those elements as a conformance error.</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"conf-15\"> </a></b>conf-15</td><td>SHALL</td><td><div><ol start=\"3\">\n<li>PAS clients and services <strong>SHALL</strong> use standard PAS data elements (i.e. elements found within PAS-defined or inherited profiles and marked as mandatory or mustSupport) to communicate needed data if such elements are intended to convey such information.</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"conf-16\"> </a></b>conf-16</td><td>MAY</td><td><div><ol start=\"4\">\n<li>PAS implementing organizations <strong>SHALL NOT</strong> publish guidance setting expectations for where certain data elements are conveyed within PAS and inherited data structures, but <strong>MAY</strong> submit change requests to PAS, HRex, or US Core requesting that additional guidance be provided to implementers on data structure usage to increase consistency across implementations.</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"metric-1\"> </a></b>metric-1</td><td>SHOULD, MAY</td><td><div><p>Each of these IGs recommends a set of metrics that <strong>SHOULD</strong> or <strong>MAY</strong> be collected by their respective implementations to facilitate the evaluation of adoption, functionality, processes, and improved outcomes.</p>\n</div></td></tr><tr><td><b><a name=\"metric-2\"> </a></b>metric-2</td><td>SHOULD</td><td><div><p>PAS implementers <strong>SHOULD</strong> store information for each PAS call in a manner that would allow them to respond to measures based on this logical model.</p>\n</div></td></tr><tr><td><b><a name=\"priv-1\"> </a></b>priv-1</td><td>SHALL</td><td><div><p>Implementations <strong>SHALL</strong> permit provider review of data prior to transmission, but <strong>SHALL NOT</strong> require such review.</p>\n</div></td></tr><tr><td><b><a name=\"priv-2\"> </a></b>priv-2</td><td>SHOULD</td><td><div><p>Payers who do not view the FHIR version of the transmitted information <strong>SHOULD</strong> be aware of the possibility of these limitations and ensure they have policies that enforce appropriate sharing constraints on data.</p>\n</div></td></tr><tr><td><b><a name=\"priv-3\"> </a></b>priv-3</td><td>SHOULD, MAY</td><td><div><p>PAS Servers <strong>SHOULD</strong> support server-server OAuth and <strong>MAY</strong> support mutually authenticated TLS.</p>\n</div></td></tr><tr><td><b><a name=\"prof-1\"> </a></b>Timings SHALL have at least a count, frequency and period, a calendarPattern, or a deliveryPattern</td><td>SHALL</td><td><div><p><strong>Each PAS Timing SHALL have at least one of:</strong></p>\n<ol>\n<li>count (with optional countMax)</li>\n<li>frequency and period and periodUnit (with optional frequencyMax and periodMax)</li>\n<li>calendarPattern extension</li>\n<li>deliveryPattern extension</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"prof-2\"> </a></b>Quantities SHALL have a value and either a unit or a code</td><td>SHALL</td><td><div><p>Each PAS Quantity SHALL have:**</p>\n<ol>\n<li>a value</li>\n<li>either a unit or a code and system.</li>\n</ol>\n</div></td></tr><tr><td><b><a name=\"prof-3\"> </a></b>prof-3</td><td>SHALL</td><td><div><p>The Claim instance of the update Bundle <strong>SHALL</strong> reference the updated Claim instance within the <code>Claim.related.claim</code> element. Note that the presence of this reference and the requirement that referenced instances be included in the submitted Bundle implies that the instance representing the prior version of the Claim <strong>SHALL</strong> be included in the update Bundle.</p>\n</div></td></tr><tr><td><b><a name=\"prof-4\"> </a></b>prof-4</td><td>SHALL</td><td><div><p>The Claim instance of the update Bundle <strong>SHALL</strong> contain within the <code>Claim.item</code> element each item requested in the updated claim and any prior versions of the claim, including requested items that have been added, modified, deleted, or left unchanged during this or previous updates.</p>\n</div></td></tr><tr><td><b><a name=\"prof-5\"> </a></b>prof-5</td><td>SHALL</td><td><div><p>The Claim instance of the update Bundle <strong>SHALL</strong> contain within the <code>Claim.supportingInfo</code> element each piece of supporting documentation submitted with the updated claim and any prior versions of claim, including supporting documentation that has been added, modified, deleted, or left unchanged during this or previous updates.</p>\n</div></td></tr><tr><td><b><a name=\"prof-6\"> </a></b>prof-6</td><td>SHALL</td><td><div><p>Each <code>Claim.item</code> entry that represents an item no longer being requested, whether removed in this update or a previous one, <strong>SHALL</strong> be flagged using the infoCancelledFlag modifierExtension and <strong>SHALL</strong> have the code <code>3</code> (Cancel) in the Certification Type extension.</p>\n</div></td></tr><tr><td><b><a name=\"prof-7\"> </a></b>prof-7</td><td>SHALL</td><td><div><p>Each <code>Claim.supportingInfo</code> entry that is no longer to be used when evaluating the request, whether removed in this update or a previous one, <strong>SHALL</strong> be flagged using the infoCancelledFlag modifierExtension.</p>\n</div></td></tr><tr><td><b><a name=\"prof-8\"> </a></b>prof-8</td><td>SHALL</td><td><div><p>Each <code>Claim.item</code> and <code>Claim.supportingInfo</code> entry that has been changed as a part of this most recent update, including removal, <strong>SHALL</strong> be flagged using the changed extension with a value of <code>changed</code>.</p>\n</div></td></tr><tr><td><b><a name=\"prof-9\"> </a></b>prof-9</td><td>SHALL</td><td><div><p>Each <code>Claim.item</code> and <code>Claim.supportingInfo</code> entry that has been added as a part of this most recent update, <strong>SHALL</strong> be flagged using the changed extension with a value of <code>added</code>.</p>\n</div></td></tr><tr><td><b><a name=\"prof-tim-2\"> </a></b>prof-tim-2</td><td>SHALL</td><td><div><p>If a code is present, it <strong>SHALL</strong> use the X12 quantity units.</p>\n</div></td></tr><tr><td><b><a name=\"spec-1\"> </a></b>spec-1</td><td>SHALL</td><td><div><p>Along with the profiles defined in the PAS implementation guide, implementations <strong>SHALL</strong> also support the US Core R4 profiles for Condition, Observation, and Procedure.</p>\n</div></td></tr><tr><td><b><a name=\"spec-2\"> </a></b>spec-2</td><td>SHOULD</td><td><div><p>They <strong>SHOULD</strong> support any other profiles relevant to the types of prior authorizations they process.</p>\n</div></td></tr><tr><td><b><a name=\"spec-3\"> </a></b>spec-3</td><td>SHOULD</td><td><div><p>Clients and Servers supporting this implementation guide <strong>SHOULD</strong> also comply with the Da Vinci <a href=\"http://www.hl7.org/fhir/us/davinci-crd\">Coverage Requirements Discovery (CRD)</a> and <a href=\"http://www.hl7.org/fhir/us/davinci-dtr\">Documentation Templates and Rules (DTR)</a> implementation guides.</p>\n</div></td></tr><tr><td><b><a name=\"spec-4\"> </a></b>spec-4</td><td>SHALL</td><td><div><p>Every system claiming conformance to this IG <strong>SHALL</strong> comply with the <a href=\"http://hl7.org/fhir/us/davinci-hrex/security.html\">Security and Privacy page in the Da Vinci HRex guide</a>.</p>\n</div></td></tr><tr><td><b><a name=\"spec-5\"> </a></b>spec-5</td><td>SHALL</td><td><div><p>If a payer supports endpoint discovery, they <strong>SHALL</strong> have at most a single endpoint for each coverage (e.g., Medicare, Medicaid, or commercial) they provide coverage under.</p>\n</div></td></tr><tr><td><b><a name=\"spec-6\"> </a></b>spec-6</td><td>SHALL</td><td><div><p>If a payer does not support endpoint discovery, they <strong>SHALL</strong> expose only one PAS endpoint capable of handling all coverages.</p>\n</div></td></tr><tr><td><b><a name=\"spec-11\"> </a></b>spec-11</td><td>SHOULD</td><td><div><p>All of this <strong>SHOULD</strong> happen synchronously with a maximum of 15 seconds between the user initiating the prior authorization request and seeing the resulting response - i.e. including network transmission time for request and response.</p>\n</div></td></tr><tr><td><b><a name=\"spec-12\"> </a></b>spec-12</td><td>SHOULD-NOT</td><td><div><p><strong>NOTE</strong>: The Claim Inquiry response does not include all of the information that can be returned in a request response, such as any request for additional information, so the inquire operation <strong>SHOULD NOT</strong> be used by the client while waiting for final results.</p>\n</div></td></tr><tr><td><b><a name=\"spec-13\"> </a></b>spec-13</td><td>MAY</td><td><div><p>Provider and EHR Vendor organizations <strong>MAY</strong> leverage the <a href=\"https://www.hl7.org/fhir/us/davinci-pdex/payertopayerexchange.html#mtls-endpoint-discovery\">payer registry</a> developed by PDex (which will eventually fold into the national directory under FAST) as a means of determining which endpoints exist for which payers as candidates for configuration.</p>\n</div></td></tr><tr><td><b><a name=\"spec-14\"> </a></b>spec-14</td><td>SHALL</td><td><div><p>The Bundle <strong>SHALL</strong> be encoded in JSON.</p>\n</div></td></tr><tr><td><b><a name=\"spec-15\"> </a></b>spec-15</td><td>SHALL</td><td><div><p>The first entry in the Bundle <strong>SHALL</strong> be a Claim resource complying with the <a href=\"StructureDefinition-profile-claim.html\">profile</a> defined in this IG to ensure the content is sufficient to appropriately populate an X12N/005010X217 message.</p>\n</div></td></tr><tr><td><b><a name=\"spec-16\"> </a></b>spec-16</td><td>SHALL</td><td><div><p>Additional Bundle entries <strong>SHALL</strong> be populated with any resources referenced by the Claim resource (and any resources referenced by <strong>those</strong> resources, fully traversing all references and complying with all identified profiles).</p>\n</div></td></tr><tr><td><b><a name=\"spec-17\"> </a></b>spec-17</td><td>SHALL</td><td><div><p>Note that even if a given resource instance is referenced multiple times, it <strong>SHALL</strong> only appear in the Bundle once.</p>\n</div></td></tr><tr><td><b><a name=\"spec-18\"> </a></b>spec-18</td><td>SHOULD</td><td><div><p>E.g., if the same Practitioner information is referenced in multiple places, only one Practitioner instance <strong>SHOULD</strong> be created - referenced from multiple places as appropriate.</p>\n</div></td></tr><tr><td><b><a name=\"spec-19\"> </a></b>spec-19</td><td>SHALL</td><td><div><p>Bundle.entry.fullUrl values <strong>SHALL</strong> be:</p>\n</div></td></tr><tr><td><b><a name=\"spec-20\"> </a></b>spec-20</td><td>SHALL</td><td><div><p>All GUIDs used <strong>SHALL</strong> be unique, including across independent prior authorization submissions - with the exception that the same resource instance being referenced in distinct prior authorization request Bundles can have the same GUID.</p>\n</div></td></tr><tr><td><b><a name=\"spec-21\"> </a></b>spec-21</td><td>SHALL</td><td><div><p>Relevant resources referenced by those "supporting information" resources <strong>SHALL</strong> also be included (e.g. prescriber Practitioner and Medication for a MedicationRequest).</p>\n</div></td></tr><tr><td><b><a name=\"spec-22\"> </a></b>spec-22</td><td>SHALL</td><td><div><p>Any such resource that has a US Core profile <strong>SHALL</strong> comply with the relevant US Core profiles.</p>\n</div></td></tr><tr><td><b><a name=\"spec-23\"> </a></b>spec-23</td><td>SHALL</td><td><div><p>All "supporting information" resources included in the Bundle <strong>SHALL</strong> be pointed to by the Claim resource using the Claim.supportingInfo.valueReference element.</p>\n</div></td></tr><tr><td><b><a name=\"spec-24\"> </a></b>spec-24</td><td>SHOULD</td><td><div><p>To attach non-FHIR instance data such as PDFs, CDAs, JPGs, a DocumentReference instance <strong>SHOULD</strong> be used.</p>\n</div></td></tr><tr><td><b><a name=\"spec-25\"> </a></b>spec-25</td><td>SHALL</td><td><div><p>The Claim.supportingInfo.sequence for each entry <strong>SHALL</strong> be unique within the Claim.</p>\n</div></td></tr><tr><td><b><a name=\"spec-26\"> </a></b>spec-26</td><td>SHALL</td><td><div><p>All resources <strong>SHALL</strong> comply with their respective profiles.</p>\n</div></td></tr><tr><td><b><a name=\"spec-27\"> </a></b>spec-27</td><td>SHOULD, MAY</td><td><div><p>FHIR elements not marked as 'must support' <strong>MAY</strong> be included in resources within the Bundle, but client systems <strong>SHOULD</strong> have no expectation of such elements being processed by the payer unless prior arrangements have been made.</p>\n</div></td></tr><tr><td><b><a name=\"spec-28\"> </a></b>spec-28</td><td>SHALL, MAY</td><td><div><p>Systems that do not process such elements <strong>SHALL</strong> ignore unsupported elements unless they are 'modifier' elements, in which case the system <strong>MAY</strong> treat the presence of the element as an error.</p>\n</div></td></tr><tr><td><b><a name=\"spec-29\"> </a></b>spec-29</td><td>SHALL</td><td><div><p>In addition, the system <strong>SHALL</strong> make the entire PAS FHIR Bundle available to the intended payer.</p>\n</div></td></tr><tr><td><b><a name=\"spec-30\"> </a></b>spec-30</td><td>MAY</td><td><div><p>The method <strong>MAY</strong> be based on the X12 275 or another method that trading partners have agreed to use.</p>\n</div></td></tr><tr><td><b><a name=\"spec-31\"> </a></b>spec-31</td><td>SHALL</td><td><div><p>If the X12 275 is used for this purpose, the 275 BDS01 Filter ID Code element <strong>SHALL</strong> be set to "B64" and the CAT02 Attachment Information Format Code element <strong>SHALL</strong> be sent to "HL".</p>\n</div></td></tr><tr><td><b><a name=\"spec-32\"> </a></b>spec-32</td><td>SHOULD</td><td><div><p>Translation/mapping systems <strong>SHOULD</strong> be aware that if the size of the attachments as part of a claims submission would exceed the size limitations of a particular recipient, the intermediary <strong>SHOULD</strong> split the attachments into separate 275s to remain within the overall limit.</p>\n</div></td></tr><tr><td><b><a name=\"spec-35\"> </a></b>spec-35</td><td>SHALL</td><td><div><p>The Bundle <strong>SHALL</strong> start with a <a href=\"StructureDefinition-profile-claimresponse-base.html\">ClaimResponse</a> entry that contains information mapped from the 278 response.</p>\n</div></td></tr><tr><td><b><a name=\"spec-36\"> </a></b>spec-36</td><td>SHALL</td><td><div><p>When converting additional Bundle entries, the conversion process <strong>SHALL</strong> ensure that only one resource is created for a given combination of content.</p>\n</div></td></tr><tr><td><b><a name=\"spec-37\"> </a></b>spec-37</td><td>SHOULD</td><td><div><p>E.g. if the same Practitioner information is referenced in multiple places, only one Practitioner instance <strong>SHOULD</strong> be created - referenced from multiple places as appropriate.</p>\n</div></td></tr><tr><td><b><a name=\"spec-38\"> </a></b>spec-38</td><td>SHALL</td><td><div><p>When echoing back resources that are the same as were present in the prior authorization request, the system <strong>SHALL</strong> ensure that the same fullUrl and resource identifiers are used in the response as appeared in the request.</p>\n</div></td></tr><tr><td><b><a name=\"spec-39\"> </a></b>spec-39</td><td>SHALL</td><td><div><p>In these instances, the receiving system <strong>SHALL</strong> return OperationOutcome instances that detail why the Bundle could not be processed and no ClaimResponse will be returned.</p>\n</div></td></tr><tr><td><b><a name=\"spec-40\"> </a></b>spec-40</td><td>SHALL</td><td><div><p>For instances where the authorized item is a modification of the requested item, the requested item <strong>SHALL</strong> be returned in the ClaimResponse.item with an adjudication status of A6 - 'Modified'.</p>\n</div></td></tr><tr><td><b><a name=\"spec-41\"> </a></b>spec-41</td><td>SHALL</td><td><div><p>The actual authorized item <strong>SHALL</strong> be returned in the ClaimResponse.addItem.</p>\n</div></td></tr><tr><td><b><a name=\"spec-42\"> </a></b>spec-42</td><td>SHOULD</td><td><div><p>The new intent of this extension is to indicate what was authorized which <strong>SHOULD</strong> match what was requested since the ClaimResponse.item does not have this information.</p>\n</div></td></tr><tr><td><b><a name=\"spec-43\"> </a></b>spec-43</td><td>SHALL</td><td><div><p>If what has been authorized is different, then the ClaimResponse.addItem <strong>SHALL</strong> be used.</p>\n</div></td></tr><tr><td><b><a name=\"spec-44\"> </a></b>spec-44</td><td>SHOULD</td><td><div><p>Recipients of the transactions <strong>SHOULD</strong> respond as indicated below and senders of the transaction <strong>SHOULD</strong> look for the following responses and then take appropriate actions.</p>\n</div></td></tr><tr><td><b><a name=\"spec-45\"> </a></b>spec-45</td><td>SHALL</td><td><div><p>All transactions in PAS are synchronous and <strong>SHALL</strong> require one of the following HTTP responses:</p>\n</div></td></tr><tr><td><b><a name=\"spec-46\"> </a></b>spec-46</td><td>SHOULD</td><td><div><p>If an OperationOutcome is received, it may have information regarding errors that <strong>SHOULD</strong> be addressed in the future, but did not cause the transaction to fail.</p>\n</div></td></tr><tr><td><b><a name=\"spec-47\"> </a></b>spec-47</td><td>SHOULD</td><td><div><p>NOTE: These errors <strong>SHOULD</strong> not be returned to the provider but <strong>SHOULD</strong> be reviewed and addressed by technical staff.</p>\n</div></td></tr><tr><td><b><a name=\"spec-48\"> </a></b>spec-48</td><td>SHOULD</td><td><div><p>Although there are no constraints on the frequency of the query, clients <strong>SHOULD</strong> ensure that no repetitive inquiries do not happen so as not to stress payer systems.</p>\n</div></td></tr><tr><td><b><a name=\"spec-49\"> </a></b>spec-49</td><td>SHOULD</td><td><div><p>To search for a specific claim, the Claim.identifier can be sent and it <strong>SHOULD</strong> be either the previously returned Administration Reference Number (REF-BB) or the Prior Authorization Number (REF-NT).</p>\n</div></td></tr><tr><td><b><a name=\"spec-50\"> </a></b>spec-50</td><td>SHALL</td><td><div><p>Intermediaries <strong>SHALL</strong> interpret the 'not-applicable' code as no product or service code.</p>\n</div></td></tr><tr><td><b><a name=\"spec-51\"> </a></b>spec-51</td><td>SHALL</td><td><div><p>This Claim Inquiry Response <strong>SHALL</strong> either reference a Claim or have a Data Absent Reason indicating why the Claim can not be referenced (eg. original claim received by fax).</p>\n</div></td></tr><tr><td><b><a name=\"spec-52\"> </a></b>spec-52</td><td>SHOULD</td><td><div><p>The referenced Claim instance <strong>SHOULD</strong> be returned if there is information in the Response that needs to be present can not be returned in the Claim Response instance.</p>\n</div></td></tr><tr><td><b><a name=\"spec-53\"> </a></b>spec-53</td><td>SHALL</td><td><div><p>the returned ClaimResponse <strong>SHALL</strong> include the current results for all submitted items, including any items changed or canceled since the original authoriation request.</p>\n</div></td></tr><tr><td><b><a name=\"spec-54\"> </a></b>spec-54</td><td>SHALL</td><td><div><p>if a specific reference number (either the REF-NT or REF-BB) is submitted and is not the 'current' number (because subsequent additions/changes/cancellations have been made to the prior authorization request), the returned record <strong>SHALL</strong> be the current authorization response - even though it no longer has the same identifier.</p>\n</div></td></tr><tr><td><b><a name=\"spec-55\"> </a></b>spec-55</td><td>SHALL</td><td><div><p>I.e. If a search is for a 'replaced' prior authorization, the search result <strong>SHALL</strong> include the 'current' prior authorization response for the most recent replacing prior authorization request.</p>\n</div></td></tr><tr><td><b><a name=\"spec-56\"> </a></b>spec-56</td><td>MAY</td><td><div><p>systems <strong>MAY</strong> withhold information about prior authorizations that are 'open' but are deemed to be not relevant to the provider (eg. prior authorization requests for sensitive care where the requesting provider is neither the ordering nor rendering provider) who is checking for the prior authorization status if not searching by a specific Claim identifier.</p>\n</div></td></tr><tr><td><b><a name=\"spec-57\"> </a></b>spec-57</td><td>SHOULD</td><td><div><p>In such situations the response <strong>SHOULD</strong> include an OperationOutcome warning that some prior authorizations have been suppressed and provide an alternative mechanism (e.g. telephone number) to provide further information if needed.</p>\n</div></td></tr><tr><td><b><a name=\"spec-58\"> </a></b>spec-58</td><td>SHALL</td><td><div><p>To retrieve the response at a later point, implementers <strong>SHALL</strong> support subscriptions.</p>\n</div></td></tr><tr><td><b><a name=\"spec-59\"> </a></b>spec-59</td><td>SHALL</td><td><div><p>Servers <strong>SHALL</strong> permit access to the prior authorization response to systems other than the original submitter.</p>\n</div></td></tr><tr><td><b><a name=\"spec-60\"> </a></b>spec-60</td><td>SHALL</td><td><div><p>They <strong>SHALL</strong> require a match on the patient member or subscriber id (identifier on the Claim.patient) plus the ordering and/or rendering provider identifier, i.e. the provider's NPI.</p>\n</div></td></tr><tr><td><b><a name=\"spec-61\"> </a></b>spec-61</td><td>SHALL</td><td><div><p>Implementers <strong>SHALL</strong> support the R4 Subscriptions referenced in the <a href=\"http://hl7.org/fhir/uv/subscriptions-backport/\">Subscriptions for R5 Backport Implementation Guide</a>.</p>\n</div></td></tr><tr><td><b><a name=\"spec-62\"> </a></b>spec-62</td><td>SHALL</td><td><div><p>This Subscription <strong>SHALL</strong> conform to the <a href=\"StructureDefinition-profile-subscription.html\">PAS Subscription profile</a>.</p>\n</div></td></tr><tr><td><b><a name=\"spec-63\"> </a></b>spec-63</td><td>SHALL</td><td><div><p>The Subscription filter criteria <strong>SHALL</strong> be org-identifier = [sending system identifier].</p>\n</div></td></tr><tr><td><b><a name=\"spec-64\"> </a></b>spec-64</td><td>SHALL</td><td><div><p>Intermediaries <strong>SHALL</strong> ensure that subscriptions to monitor a particular sending system's prior authorizations are only created or modified by that sending system.</p>\n</div></td></tr><tr><td><b><a name=\"spec-65\"> </a></b>spec-65</td><td>SHALL</td><td><div><p>Servers supporting subscriptions <strong>SHALL</strong> expose this as part of the Server's CapabilityStatement</p>\n</div></td></tr><tr><td><b><a name=\"spec-66\"> </a></b>spec-66</td><td>SHALL</td><td><div><p>Servers <strong>SHALL</strong> support rest-hook</p>\n</div></td></tr><tr><td><b><a name=\"spec-67\"> </a></b>spec-67</td><td>SHALL</td><td><div><p>Once the <a href=\"Subscription-PASSubscriptionExample.html\">subscription</a> has been created, the Server <strong>SHALL</strong> send a notification over the requested channel indicating that a prior authorization response submitted by the requesting provider organization has changed.</p>\n</div></td></tr><tr><td><b><a name=\"spec-68\"> </a></b>spec-68</td><td>SHALL</td><td><div><p>Due to the inquiry not supporting all of the required information needed in a PAS response, PAS Clients and Intermediaries <strong>SHALL</strong> only support subscriptions with content='full-resource'.</p>\n</div></td></tr><tr><td><b><a name=\"spec-70\"> </a></b>spec-70</td><td>SHOULD</td><td><div><p>When details of a submitted request change and a provider needs to request prior authorization of a different set of items, clients <strong>SHOULD</strong> submit an update to the previously submitted Claim.</p>\n</div></td></tr><tr><td><b><a name=\"spec-71\"> </a></b>spec-71</td><td>MAY</td><td><div><p>Servers <strong>MAY</strong> reject updates and require that a new request is made by providing the appropriate X12 error code.</p>\n</div></td></tr><tr><td><b><a name=\"spec-72\"> </a></b>spec-72</td><td>SHALL</td><td><div><p>Systems <strong>SHALL</strong> communicate a cancellation of an item if the corresponding order is canceled and a final authorization determination has not yet been received for that item.</p>\n</div></td></tr><tr><td><b><a name=\"spec-73\"> </a></b>spec-73</td><td>SHOULD</td><td><div><p>This is appropriate if the added items share the same context and <strong>SHOULD</strong> be evaluated in conjunction with the other items in the previously submitted authorization request.</p>\n</div></td></tr><tr><td><b><a name=\"spec-74\"> </a></b>spec-74</td><td>SHALL</td><td><div><p>The Claim Update Bundle <strong>SHALL</strong> contain the Claim Update instance as the first entry.</p>\n</div></td></tr><tr><td><b><a name=\"spec-75\"> </a></b>spec-75</td><td>SHALL</td><td><div><p>The Claim that is being updated <strong>SHALL</strong> be included in the Bundle.</p>\n</div></td></tr><tr><td><b><a name=\"spec-76\"> </a></b>spec-76</td><td/><td><div><p>If that Claim instance is itself a Claim Update, its referenced Claim <strong>SHALL NOT</strong> be included.</p>\n</div></td></tr><tr><td><b><a name=\"spec-77\"> </a></b>spec-77</td><td>SHALL</td><td><div><p>All other referenced resources <strong>SHALL</strong> be included in the Bundle.</p>\n</div></td></tr><tr><td><b><a name=\"spec-78\"> </a></b>spec-78</td><td>SHALL</td><td><div><p>PAS systems <strong>SHALL</strong> ensure that prior authorizations that were initially pended remain available for query for at least 6 months after the anticipated completion of the services whose authorization was requested.</p>\n</div></td></tr><tr><td><b><a name=\"use-1\"> </a></b>use-1</td><td>SHALL</td><td><div><p>The intermediary <strong>SHALL</strong> always exchange a FHIR bundle with the EHR (figure 2.3)</p>\n</div></td></tr><tr><td><b><a name=\"use-2\"> </a></b>use-2</td><td>SHALL</td><td><div><p>The intermediary <strong>SHALL</strong> convert the FHIR bundle to and from an X12 278 (and optionally to an X12 275) if necessary to meet the HIPAA transaction requirements</p>\n</div></td></tr><tr><td><b><a name=\"use-3\"> </a></b>use-3</td><td>MAY</td><td><div><p>The intermediary <strong>MAY</strong> convert the X12 278 to and from a FHIR bundle and exchange it with a payer as long as the PA request and response are in an X12 278 format at some time between the exchange with the EHR and the payer</p>\n</div></td></tr><tr><td><b><a name=\"use-4\"> </a></b>use-4</td><td>SHOULD</td><td><div><p>As well, EHRs <strong>SHOULD</strong> annotate their orders with the decisions contained in the PAS Response.</p>\n</div></td></tr><tr><td><b><a name=\"use-5\"> </a></b>use-5</td><td>SHALL</td><td><div><p>Prior to sending clinical data as part of the PAS exchange, the provider (or their designated agent) <strong>SHALL</strong> have the ability, but not an obligation, to review patient information and where appropriate amend or withhold the submission to comply with current regulations and relevant provider policies. The provider can choose to turn off the ability to review documentation. The vendor must allow them this option.</p>\n</div></td></tr><tr><td><b><a name=\"use-6\"> </a></b>use-6</td><td>SHOULD</td><td><div><p>All exchanges <strong>SHOULD</strong> meet Federal and state regulations, including any HIPAA restrictions and restrictions on sensitive data.</p>\n</div></td></tr></table></div>"
},
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode" : "fm"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger" : 4,
"_valueInteger" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas|2.2.0-snapshot"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas|2.2.0-snapshot"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"
}
]
}
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode" : "trial-use",
"_valueCode" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
"valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"
}
]
}
}
],
"url" : "http://hl7.org/fhir/us/davinci-pas/Requirements/fromNarrative",
"identifier" : [
{
"system" : "urn:ietf:rfc:3986",
"value" : "urn:oid:2.16.840.1.113883.4.642.40.24.36.1"
}
],
"version" : "2.2.0-snapshot",
"name" : "FromNarrative",
"title" : "Narrative Conformance Statements",
"status" : "active",
"experimental" : false,
"date" : "2026-01-30T14:13:33-07:00",
"publisher" : "HL7 International / Financial Management",
"contact" : [
{
"name" : "HL7 International / Financial Management",
"telecom" : [
{
"system" : "url",
"value" : "http://hl7.org/Special/committees/fm"
},
{
"system" : "email",
"value" : "fmlists@lists.hl7.org"
}
]
},
{
"name" : "Jean Duteau",
"telecom" : [
{
"system" : "email",
"value" : "mailto:jean@duteaudesign.com"
}
]
},
{
"name" : "HL7 International / Financial Management",
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/fm"
}
]
}
],
"description" : "Conformance statements found throughout the narrative of the IG consolidated into this computable resource for traceability purposes",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US",
"display" : "United States of America"
}
]
}
],
"actor" : [
🔗 "http://hl7.org/fhir/us/davinci-pas/ActorDefinition/client"🔗 ,
"http://hl7.org/fhir/us/davinci-pas/ActorDefinition/payer"
],
"_actor" : [
{
🔗 "extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-actorkey",
"valueString" : "client"
}
]
},
{
🔗 "extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-actorkey",
"valueString" : "payer"
}
]
}
],
"statement" : [
{
"key" : "1",
"conformance" : [
"SHALL"
],
"requirement" : "spec-77:A subscription-based mechanism SHALL be used by the client to be informed of updates to the authorization."
},
{
"key" : "2",
"conformance" : [
"SHALL"
],
"requirement" : "spec-77:A subscription-based mechanism SHALL be used by the client to be informed of updates to the authorization."
},
{
"key" : "3",
"conformance" : [
"SHALL"
],
"requirement" : "spec-33:Each item returned on the PAS ClaimResponse SHALL echo the same item.sequence as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses."
},
{
"key" : "4",
"conformance" : [
"SHALL"
],
"requirement" : "spec-33:Each item returned on the PAS ClaimResponse SHALL echo the same item.sequence as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-1",
"label" : "Payers MAY request additional information in a number of ways",
"conformance" : [
"MAY"
],
"requirement" : "A payer **MAY** request additional information from the provider to support a prior authorization request by responding to the X12 278 Request with an X12 278 Response that includes any of the following:\r\n\r\n1. One or more codes in the PWK01 element\r\n1. One or more of the approved LOINC codes Attachments – LOINC in the HI segment\r\n1. A single 102089-0 LOINC code in the HI segment to request information via a payer’s specific questionnaire."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-2",
"conformance" : [
"SHALL"
],
"requirement" : "When a single LOINC code is used, the TRN at the X12 278 header or line level associated with the 102089-0 LOINC code **SHALL** be the DTR context ID used to retrieve the appropriate questionnaire."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-3",
"conformance" : [
"SHALL"
],
"requirement" : "The [PAS task profile](StructureDefinition-profile-task.html) **SHALL** be used to convey PAS X12 278 Response information to CDex."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-4",
"conformance" : [
"SHOULD"
],
"requirement" : "All of the additional information request codes **SHOULD** be used as input to a CDex task."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-5",
"conformance" : [
"SHALL"
],
"requirement" : "When the LOINC code 102089-0 is present, the associated TRNs **SHALL** also be exchange as Task.input."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "ainfo-6",
"conformance" : [
"SHALL"
],
"requirement" : "A separate task **SHALL** be created for each of the above attachment request types (PWK01, LOINC, questionnaire)."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-1",
"conformance" : [
"SHALL"
],
"requirement" : "Payers **SHALL** have a distinct endpoint for each different supported version (which are not inter-version compatible) of the PAS specification."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-2",
"conformance" : [
"SHALL"
],
"requirement" : "If a payer supports endpoint discovery, they **SHALL** have at most a single endpoint for each combination of version of the specification and coverage (e.g., Medicare, Medicaid, or commercial) they provide coverage under."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-3",
"conformance" : [
"SHALL"
],
"requirement" : "If a payer does not support endpoint discovery, they **SHALL** expose only one PAS endpoint of each supported version capable of handling all coverages."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-4",
"conformance" : [
"SHALL"
],
"requirement" : "PA Intermediary Systems **SHALL** be capable of processing all data elements that are marked as Must Support on the Claim Request and Claim Inquiry."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-5",
"requirement" : "They **SHALL NOT** generate an error or cause the application to fail due the presence of any data element marked as Must Support."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-6",
"conformance" : [
"SHALL"
],
"requirement" : "PA Intermediary Systems **SHALL** be capable of returning resource instances containing any of the data elements that are marked as Must Support on the Claim Response and the Claim Inquiry Response."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "conf-7",
"conformance" : [
"SHALL"
],
"requirement" : "PA Client Systems **SHALL** be capable of receiving all data elements that are marked as Must Support on the Claim Response and the Claim Inquiry Response."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "conf-8",
"requirement" : "They **SHALL NOT** generate an error or cause the application to fail when receiving any data element that is marked as Must Support."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "conf-9",
"conformance" : [
"SHOULD-NOT"
],
"requirement" : "PA Client Systems **SHOULD NOT** send any data elements that are not marked as Must Support."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-10",
"conformance" : [
"MAY"
],
"requirement" : "If these data elements are included in a Claim Request or Claim Inquiry, the receiving PA Intermediary System **MAY** ignore those elements."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-11",
"requirement" : "When processing prior auth requests and additional data submissions, PAS services **SHALL NOT** depend on or set expectations for the inclusion of resource instances not compliant with profiles defined in this guide, CRD, DTR, HRex, or US Core."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-12",
"requirement" : "Similarly, they **SHALL NOT** depend on or set expectations for the inclusion of any data elements not marked as mandatory (min cardinality >= 1) or mustSupport in those profiles."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-13",
"conformance" : [
"MAY"
],
"requirement" : "If the proposed change is adopted and published in the PAS continuous integration build or the CI build of one of its dependencies (e.g. US Core), implementations **MAY**, by mutual agreement, pre-adopt the use of those additional profiles and/or mustSupport data elements and not be considered in violation of #1 above."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
}
],
"key" : "conf-14",
"requirement" : "2. Where cardinality and other constraints present in profiles allow data elements to be omitted, PAS compliant systems **SHALL NOT** treat the omission of those elements as a conformance error."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-15",
"conformance" : [
"SHALL"
],
"requirement" : "3. PAS clients and services **SHALL** use standard PAS data elements (i.e. elements found within PAS-defined or inherited profiles and marked as mandatory or mustSupport) to communicate needed data if such elements are intended to convey such information."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "conf-16",
"conformance" : [
"MAY"
],
"requirement" : "4. PAS implementing organizations **SHALL NOT** publish guidance setting expectations for where certain data elements are conveyed within PAS and inherited data structures, but **MAY** submit change requests to PAS, HRex, or US Core requesting that additional guidance be provided to implementers on data structure usage to increase consistency across implementations."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "storage",
"display" : "storage"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "metric-1",
"conformance" : [
"SHOULD",
"MAY"
],
"requirement" : "Each of these IGs recommends a set of metrics that **SHOULD** or **MAY** be collected by their respective implementations to facilitate the evaluation of adoption, functionality, processes, and improved outcomes."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "storage",
"display" : "storage"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "metric-2",
"conformance" : [
"SHOULD"
],
"requirement" : "PAS implementers **SHOULD** store information for each PAS call in a manner that would allow them to respond to measures based on this logical model."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "privacy",
"display" : "privacy"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "priv-1",
"conformance" : [
"SHALL"
],
"requirement" : "Implementations **SHALL** permit provider review of data prior to transmission, but **SHALL NOT** require such review."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "privacy",
"display" : "privacy"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "priv-2",
"conformance" : [
"SHOULD"
],
"requirement" : "Payers who do not view the FHIR version of the transmitted information **SHOULD** be aware of the possibility of these limitations and ensure they have policies that enforce appropriate sharing constraints on data."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "privacy",
"display" : "privacy"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "priv-3",
"conformance" : [
"SHOULD",
"MAY"
],
"requirement" : "PAS Servers **SHOULD** support server-server OAuth and **MAY** support mutually authenticated TLS."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "prof-1",
"label" : "Timings SHALL have at least a count, frequency and period, a calendarPattern, or a deliveryPattern",
"conformance" : [
"SHALL"
],
"requirement" : "**Each PAS Timing SHALL have at least one of:**\r\n\r\n1. count (with optional countMax)\r\n1. frequency and period and periodUnit (with optional frequencyMax and periodMax)\r\n1. calendarPattern extension\r\n1. deliveryPattern extension"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "prof-2",
"label" : "Quantities SHALL have a value and either a unit or a code",
"conformance" : [
"SHALL"
],
"requirement" : "Each PAS Quantity SHALL have:**\r\n\r\n1. a value\r\n1. either a unit or a code and system."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-3",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim instance of the update Bundle **SHALL** reference the updated Claim instance within the `Claim.related.claim` element. Note that the presence of this reference and the requirement that referenced instances be included in the submitted Bundle implies that the instance representing the prior version of the Claim **SHALL** be included in the update Bundle."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-4",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim instance of the update Bundle **SHALL** contain within the `Claim.item` element each item requested in the updated claim and any prior versions of the claim, including requested items that have been added, modified, deleted, or left unchanged during this or previous updates."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-5",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim instance of the update Bundle **SHALL** contain within the `Claim.supportingInfo` element each piece of supporting documentation submitted with the updated claim and any prior versions of claim, including supporting documentation that has been added, modified, deleted, or left unchanged during this or previous updates."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-6",
"conformance" : [
"SHALL"
],
"requirement" : "Each `Claim.item` entry that represents an item no longer being requested, whether removed in this update or a previous one, **SHALL** be flagged using the infoCancelledFlag modifierExtension and **SHALL** have the code `3` (Cancel) in the Certification Type extension."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-7",
"conformance" : [
"SHALL"
],
"requirement" : "Each `Claim.supportingInfo` entry that is no longer to be used when evaluating the request, whether removed in this update or a previous one, **SHALL** be flagged using the infoCancelledFlag modifierExtension."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-8",
"conformance" : [
"SHALL"
],
"requirement" : "Each `Claim.item` and `Claim.supportingInfo` entry that has been changed as a part of this most recent update, including removal, **SHALL** be flagged using the changed extension with a value of `changed`."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "prof-9",
"conformance" : [
"SHALL"
],
"requirement" : "Each `Claim.item` and `Claim.supportingInfo` entry that has been added as a part of this most recent update, **SHALL** be flagged using the changed extension with a value of `added`."
},
{
"key" : "prof-tim-2",
"conformance" : [
"SHALL"
],
"requirement" : "If a code is present, it **SHALL** use the X12 quantity units."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-1",
"conformance" : [
"SHALL"
],
"conditionality" : true,
"requirement" : "Along with the profiles defined in the PAS implementation guide, implementations **SHALL** also support the US Core R4 profiles for Condition, Observation, and Procedure."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-2",
"conformance" : [
"SHOULD"
],
"conditionality" : true,
"requirement" : "They **SHOULD** support any other profiles relevant to the types of prior authorizations they process."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-3",
"conformance" : [
"SHOULD"
],
"conditionality" : true,
"requirement" : "Clients and Servers supporting this implementation guide **SHOULD** also comply with the Da Vinci [Coverage Requirements Discovery (CRD)](http://www.hl7.org/fhir/us/davinci-crd) and [Documentation Templates and Rules (DTR)](http://www.hl7.org/fhir/us/davinci-dtr) implementation guides."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-4",
"conformance" : [
"SHALL"
],
"conditionality" : true,
"requirement" : "Every system claiming conformance to this IG **SHALL** comply with the [Security and Privacy page in the Da Vinci HRex guide](http://hl7.org/fhir/us/davinci-hrex/security.html)."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-5",
"conformance" : [
"SHALL"
],
"conditionality" : true,
"requirement" : "If a payer supports endpoint discovery, they **SHALL** have at most a single endpoint for each coverage (e.g., Medicare, Medicaid, or commercial) they provide coverage under."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "spec-6",
"conformance" : [
"SHALL"
],
"conditionality" : true,
"requirement" : "If a payer does not support endpoint discovery, they **SHALL** expose only one PAS endpoint capable of handling all coverages."
},
{
"key" : "spec-11",
"conformance" : [
"SHOULD"
],
"requirement" : "All of this **SHOULD** happen synchronously with a maximum of 15 seconds between the user initiating the prior authorization request and seeing the resulting response - i.e. including network transmission time for request and response."
},
{
"key" : "spec-12",
"conformance" : [
"SHOULD-NOT"
],
"requirement" : "**NOTE**: The Claim Inquiry response does not include all of the information that can be returned in a request response, such as any request for additional information, so the inquire operation **SHOULD NOT** be used by the client while waiting for final results."
},
{
"key" : "spec-13",
"conformance" : [
"MAY"
],
"requirement" : "Provider and EHR Vendor organizations **MAY** leverage the [payer registry](https://www.hl7.org/fhir/us/davinci-pdex/payertopayerexchange.html#mtls-endpoint-discovery) developed by PDex (which will eventually fold into the national directory under FAST) as a means of determining which endpoints exist for which payers as candidates for configuration."
},
{
"key" : "spec-14",
"conformance" : [
"SHALL"
],
"requirement" : "The Bundle **SHALL** be encoded in JSON."
},
{
"key" : "spec-15",
"conformance" : [
"SHALL"
],
"requirement" : "The first entry in the Bundle **SHALL** be a Claim resource complying with the [profile](StructureDefinition-profile-claim.html) defined in this IG to ensure the content is sufficient to appropriately populate an X12N/005010X217 message."
},
{
"key" : "spec-16",
"conformance" : [
"SHALL"
],
"requirement" : "Additional Bundle entries **SHALL** be populated with any resources referenced by the Claim resource (and any resources referenced by **those** resources, fully traversing all references and complying with all identified profiles)."
},
{
"key" : "spec-17",
"conformance" : [
"SHALL"
],
"requirement" : "Note that even if a given resource instance is referenced multiple times, it **SHALL** only appear in the Bundle once."
},
{
"key" : "spec-18",
"conformance" : [
"SHOULD"
],
"requirement" : "E.g., if the same Practitioner information is referenced in multiple places, only one Practitioner instance **SHOULD** be created - referenced from multiple places as appropriate."
},
{
"key" : "spec-19",
"conformance" : [
"SHALL"
],
"requirement" : "Bundle.entry.fullUrl values **SHALL** be:"
},
{
"key" : "spec-20",
"conformance" : [
"SHALL"
],
"requirement" : "All GUIDs used **SHALL** be unique, including across independent prior authorization submissions - with the exception that the same resource instance being referenced in distinct prior authorization request Bundles can have the same GUID."
},
{
"key" : "spec-21",
"conformance" : [
"SHALL"
],
"requirement" : "Relevant resources referenced by those \"supporting information\" resources **SHALL** also be included (e.g. prescriber Practitioner and Medication for a MedicationRequest)."
},
{
"key" : "spec-22",
"conformance" : [
"SHALL"
],
"requirement" : "Any such resource that has a US Core profile **SHALL** comply with the relevant US Core profiles."
},
{
"key" : "spec-23",
"conformance" : [
"SHALL"
],
"requirement" : "All \"supporting information\" resources included in the Bundle **SHALL** be pointed to by the Claim resource using the Claim.supportingInfo.valueReference element."
},
{
"key" : "spec-24",
"conformance" : [
"SHOULD"
],
"requirement" : "To attach non-FHIR instance data such as PDFs, CDAs, JPGs, a DocumentReference instance **SHOULD** be used."
},
{
"key" : "spec-25",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim.supportingInfo.sequence for each entry **SHALL** be unique within the Claim."
},
{
"key" : "spec-26",
"conformance" : [
"SHALL"
],
"requirement" : "All resources **SHALL** comply with their respective profiles."
},
{
"key" : "spec-27",
"conformance" : [
"SHOULD",
"MAY"
],
"requirement" : "FHIR elements not marked as 'must support' **MAY** be included in resources within the Bundle, but client systems **SHOULD** have no expectation of such elements being processed by the payer unless prior arrangements have been made."
},
{
"key" : "spec-28",
"conformance" : [
"SHALL",
"MAY"
],
"requirement" : "Systems that do not process such elements **SHALL** ignore unsupported elements unless they are 'modifier' elements, in which case the system **MAY** treat the presence of the element as an error."
},
{
"key" : "spec-29",
"conformance" : [
"SHALL"
],
"requirement" : "In addition, the system **SHALL** make the entire PAS FHIR Bundle available to the intended payer."
},
{
"key" : "spec-30",
"conformance" : [
"MAY"
],
"requirement" : "The method **MAY** be based on the X12 275 or another method that trading partners have agreed to use."
},
{
"key" : "spec-31",
"conformance" : [
"SHALL"
],
"requirement" : "If the X12 275 is used for this purpose, the 275 BDS01 Filter ID Code element **SHALL** be set to \"B64\" and the CAT02 Attachment Information Format Code element **SHALL** be sent to \"HL\"."
},
{
"key" : "spec-32",
"conformance" : [
"SHOULD"
],
"requirement" : "Translation/mapping systems **SHOULD** be aware that if the size of the attachments as part of a claims submission would exceed the size limitations of a particular recipient, the intermediary **SHOULD** split the attachments into separate 275s to remain within the overall limit."
},
{
"key" : "spec-35",
"conformance" : [
"SHALL"
],
"requirement" : "The Bundle **SHALL** start with a [ClaimResponse](StructureDefinition-profile-claimresponse-base.html) entry that contains information mapped from the 278 response."
},
{
"key" : "spec-36",
"conformance" : [
"SHALL"
],
"requirement" : "When converting additional Bundle entries, the conversion process **SHALL** ensure that only one resource is created for a given combination of content."
},
{
"key" : "spec-37",
"conformance" : [
"SHOULD"
],
"requirement" : "E.g. if the same Practitioner information is referenced in multiple places, only one Practitioner instance **SHOULD** be created - referenced from multiple places as appropriate."
},
{
"key" : "spec-38",
"conformance" : [
"SHALL"
],
"requirement" : "When echoing back resources that are the same as were present in the prior authorization request, the system **SHALL** ensure that the same fullUrl and resource identifiers are used in the response as appeared in the request."
},
{
"key" : "spec-39",
"conformance" : [
"SHALL"
],
"requirement" : "In these instances, the receiving system **SHALL** return OperationOutcome instances that detail why the Bundle could not be processed and no ClaimResponse will be returned."
},
{
"key" : "spec-40",
"conformance" : [
"SHALL"
],
"requirement" : "For instances where the authorized item is a modification of the requested item, the requested item **SHALL** be returned in the ClaimResponse.item with an adjudication status of A6 - 'Modified'."
},
{
"key" : "spec-41",
"conformance" : [
"SHALL"
],
"requirement" : "The actual authorized item **SHALL** be returned in the ClaimResponse.addItem."
},
{
"key" : "spec-42",
"conformance" : [
"SHOULD"
],
"requirement" : "The new intent of this extension is to indicate what was authorized which **SHOULD** match what was requested since the ClaimResponse.item does not have this information."
},
{
"key" : "spec-43",
"conformance" : [
"SHALL"
],
"requirement" : "If what has been authorized is different, then the ClaimResponse.addItem **SHALL** be used."
},
{
"key" : "spec-44",
"conformance" : [
"SHOULD"
],
"requirement" : "Recipients of the transactions **SHOULD** respond as indicated below and senders of the transaction **SHOULD** look for the following responses and then take appropriate actions."
},
{
"key" : "spec-45",
"conformance" : [
"SHALL"
],
"requirement" : "All transactions in PAS are synchronous and **SHALL** require one of the following HTTP responses:"
},
{
"key" : "spec-46",
"conformance" : [
"SHOULD"
],
"requirement" : "If an OperationOutcome is received, it may have information regarding errors that **SHOULD** be addressed in the future, but did not cause the transaction to fail."
},
{
"key" : "spec-47",
"conformance" : [
"SHOULD"
],
"requirement" : "NOTE: These errors **SHOULD** not be returned to the provider but **SHOULD** be reviewed and addressed by technical staff."
},
{
"key" : "spec-48",
"conformance" : [
"SHOULD"
],
"requirement" : "Although there are no constraints on the frequency of the query, clients **SHOULD** ensure that no repetitive inquiries do not happen so as not to stress payer systems."
},
{
"key" : "spec-49",
"conformance" : [
"SHOULD"
],
"requirement" : "To search for a specific claim, the Claim.identifier can be sent and it **SHOULD** be either the previously returned Administration Reference Number (REF-BB) or the Prior Authorization Number (REF-NT)."
},
{
"key" : "spec-50",
"conformance" : [
"SHALL"
],
"requirement" : "Intermediaries **SHALL** interpret the 'not-applicable' code as no product or service code."
},
{
"key" : "spec-51",
"conformance" : [
"SHALL"
],
"requirement" : "This Claim Inquiry Response **SHALL** either reference a Claim or have a Data Absent Reason indicating why the Claim can not be referenced (eg. original claim received by fax)."
},
{
"key" : "spec-52",
"conformance" : [
"SHOULD"
],
"requirement" : "The referenced Claim instance **SHOULD** be returned if there is information in the Response that needs to be present can not be returned in the Claim Response instance."
},
{
"key" : "spec-53",
"conformance" : [
"SHALL"
],
"requirement" : "the returned ClaimResponse **SHALL** include the current results for all submitted items, including any items changed or canceled since the original authoriation request."
},
{
"key" : "spec-54",
"conformance" : [
"SHALL"
],
"requirement" : "if a specific reference number (either the REF-NT or REF-BB) is submitted and is not the 'current' number (because subsequent additions/changes/cancellations have been made to the prior authorization request), the returned record **SHALL** be the current authorization response - even though it no longer has the same identifier."
},
{
"key" : "spec-55",
"conformance" : [
"SHALL"
],
"requirement" : "I.e. If a search is for a 'replaced' prior authorization, the search result **SHALL** include the 'current' prior authorization response for the most recent replacing prior authorization request."
},
{
"key" : "spec-56",
"conformance" : [
"MAY"
],
"requirement" : "systems **MAY** withhold information about prior authorizations that are 'open' but are deemed to be not relevant to the provider (eg. prior authorization requests for sensitive care where the requesting provider is neither the ordering nor rendering provider) who is checking for the prior authorization status if not searching by a specific Claim identifier."
},
{
"key" : "spec-57",
"conformance" : [
"SHOULD"
],
"requirement" : "In such situations the response **SHOULD** include an OperationOutcome warning that some prior authorizations have been suppressed and provide an alternative mechanism (e.g. telephone number) to provide further information if needed."
},
{
"key" : "spec-58",
"conformance" : [
"SHALL"
],
"requirement" : "To retrieve the response at a later point, implementers **SHALL** support subscriptions."
},
{
"key" : "spec-59",
"conformance" : [
"SHALL"
],
"requirement" : "Servers **SHALL** permit access to the prior authorization response to systems other than the original submitter."
},
{
"key" : "spec-60",
"conformance" : [
"SHALL"
],
"requirement" : "They **SHALL** require a match on the patient member or subscriber id (identifier on the Claim.patient) plus the ordering and/or rendering provider identifier, i.e. the provider's NPI."
},
{
"key" : "spec-61",
"conformance" : [
"SHALL"
],
"requirement" : "Implementers **SHALL** support the R4 Subscriptions referenced in the [Subscriptions for R5 Backport Implementation Guide](http://hl7.org/fhir/uv/subscriptions-backport/)."
},
{
"key" : "spec-62",
"conformance" : [
"SHALL"
],
"requirement" : "This Subscription **SHALL** conform to the [PAS Subscription profile](StructureDefinition-profile-subscription.html)."
},
{
"key" : "spec-63",
"conformance" : [
"SHALL"
],
"requirement" : "The Subscription filter criteria **SHALL** be org-identifier = [sending system identifier]."
},
{
"key" : "spec-64",
"conformance" : [
"SHALL"
],
"requirement" : "Intermediaries **SHALL** ensure that subscriptions to monitor a particular sending system's prior authorizations are only created or modified by that sending system."
},
{
"key" : "spec-65",
"conformance" : [
"SHALL"
],
"requirement" : "Servers supporting subscriptions **SHALL** expose this as part of the Server's CapabilityStatement"
},
{
"key" : "spec-66",
"conformance" : [
"SHALL"
],
"requirement" : "Servers **SHALL** support rest-hook"
},
{
"key" : "spec-67",
"conformance" : [
"SHALL"
],
"requirement" : "Once the [subscription](Subscription-PASSubscriptionExample.html) has been created, the Server **SHALL** send a notification over the requested channel indicating that a prior authorization response submitted by the requesting provider organization has changed."
},
{
"key" : "spec-68",
"conformance" : [
"SHALL"
],
"requirement" : "Due to the inquiry not supporting all of the required information needed in a PAS response, PAS Clients and Intermediaries **SHALL** only support subscriptions with content='full-resource'."
},
{
"key" : "spec-70",
"conformance" : [
"SHOULD"
],
"requirement" : "When details of a submitted request change and a provider needs to request prior authorization of a different set of items, clients **SHOULD** submit an update to the previously submitted Claim."
},
{
"key" : "spec-71",
"conformance" : [
"MAY"
],
"requirement" : "Servers **MAY** reject updates and require that a new request is made by providing the appropriate X12 error code."
},
{
"key" : "spec-72",
"conformance" : [
"SHALL"
],
"requirement" : "Systems **SHALL** communicate a cancellation of an item if the corresponding order is canceled and a final authorization determination has not yet been received for that item."
},
{
"key" : "spec-73",
"conformance" : [
"SHOULD"
],
"requirement" : "This is appropriate if the added items share the same context and **SHOULD** be evaluated in conjunction with the other items in the previously submitted authorization request."
},
{
"key" : "spec-74",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim Update Bundle **SHALL** contain the Claim Update instance as the first entry."
},
{
"key" : "spec-75",
"conformance" : [
"SHALL"
],
"requirement" : "The Claim that is being updated **SHALL** be included in the Bundle."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementshallnot",
"valueBoolean" : true
}
],
"key" : "spec-76",
"requirement" : "If that Claim instance is itself a Claim Update, its referenced Claim **SHALL NOT** be included."
},
{
"key" : "spec-77",
"conformance" : [
"SHALL"
],
"requirement" : "All other referenced resources **SHALL** be included in the Bundle."
},
{
"key" : "spec-78",
"conformance" : [
"SHALL"
],
"requirement" : "PAS systems **SHALL** ensure that prior authorizations that were initially pended remain available for query for at least 6 months after the anticipated completion of the services whose authorization was requested."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "use-1",
"conformance" : [
"SHALL"
],
"requirement" : "The intermediary **SHALL** always exchange a FHIR bundle with the EHR (figure 2.3)"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "use-2",
"conformance" : [
"SHALL"
],
"requirement" : "The intermediary **SHALL** convert the FHIR bundle to and from an X12 278 (and optionally to an X12 275) if necessary to meet the HIPAA transaction requirements"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "use-3",
"conformance" : [
"MAY"
],
"requirement" : "The intermediary **MAY** convert the X12 278 to and from a FHIR bundle and exchange it with a payer as long as the PA request and response are in an X12 278 format at some time between the exchange with the EHR and the payer"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "use-4",
"conformance" : [
"SHOULD"
],
"requirement" : "As well, EHRs **SHOULD** annotate their orders with the decisions contained in the PAS Response."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "privacy",
"display" : "privacy"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
}
],
"key" : "use-5",
"conformance" : [
"SHALL"
],
"requirement" : "Prior to sending clinical data as part of the PAS exchange, the provider (or their designated agent) **SHALL** have the ability, but not an obligation, to review patient information and where appropriate amend or withhold the submission to comply with current regulations and relevant provider policies. The provider can choose to turn off the ability to review documentation. The vendor must allow them this option."
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementcategory",
"valueCoding" : {
"system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
"code" : "exchange",
"display" : "exchange"
}
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "client"
},
{
"url" : "http://hl7.org/fhir/tools/StructureDefinition/requirements-statementactor",
"valueString" : "payer"
}
],
"key" : "use-6",
"conformance" : [
"SHOULD"
],
"requirement" : "All exchanges **SHOULD** meet Federal and state regulations, including any HIPAA restrictions and restrictions on sensitive data."
}
]
}
IG © 2020+ HL7 International / Financial Management.
Package hl7.fhir.us.davinci-pas#2.2.0-snapshot based on FHIR 4.0.1.
Generated
2026-01-30
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