Da Vinci Prior Authorization Support (PAS) FHIR IG
1.0.0 - STU 1

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 1.0.0). 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 conforming to this implementation guide

ClaimInquiryOperation

This operation is used to make an inquiry for a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) as a Bundle containing the Claim and other referenced resources for processing. The only input parameter is the single Bundle resource with a Claim instance (along with other referenced resources) and the only output is a single Bundle with a ClaimResponse (and other referenced resources) or an OperationOutcome resource.

ClaimSubmitOperation

This operation is used to submit a Claim, Pre-Authorization or Pre-Determination (all instances of Claim resources) for adjudication as a Bundle containing the Claim and other referenced resources for processing. The only input parameter is the single Bundle resource with a Claim instance (along with other referenced resources) and the only output is a single Bundle with a ClaimResponse (and other referenced resources) or an OperationOutcome resource.

Structures: Resource Profiles

These define constraints on FHIR resources for systems conforming to this implementation guide

PAS Beneficiary Patient

A patient who is the beneficiary of an insurance plan.

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 the Encounter resource mandating support for elements relevant to details of a requested institutional stay on the prior authorization request

PAS Inquiry Request Bundle

PAS constraints on Bundle resource ensuring that a claim inquiry resource is present and that non-supported elements are not.

PAS Inquiry Response Bundle

PAS constraints on Bundle resource ensuring that a claim inquiry response resource is present and that non-supported elements are not.

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 Request Bundle

PAS constraints on Bundle resource ensuring that a claim/claim update resource is present and that non-supported elements are not.

PAS Requestor Organization

The organization who is making a prior authorization request.

PAS Response Bundle

PAS constraints on Bundle resource ensuring that a claim response resource is present and that non-supported elements are not.

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 for systems conforming to this implementation guide

PAS Timing

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

Structures: Extension Definitions

These define constraints on FHIR data types for systems conforming to this implementation guide

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 by which the item that is pre-authorized must be completed.

AuthorizedItemDetail

The details of what has been authorized for this item 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.

ErrorElement

The specific loop, segment, or element that this error information is about.

FollowupAction

A code representing what action must occur to resolve this error.

IdentifierSubDepartment

An additional element that provides the subdepartment that created the authorization request.

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 to this implementation guide

AHA NUBC Revenue Value Set

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).

PAS Information Change Mode Value Set

The mode by which a piece of information has changed.

PAS Supporting Info Type Value Set

Types of supporting information for a Prior Authorization Claim.

X12 278 Diagnosis Code Value Set

The complete set of codes that can be used to convey a patient diagnosis. This includes codes from ICD-10-CM, ICD-9-CM and Diagnosis Related Group codes.

X12 278 Diagnosis Information Type

LOINC codes that convey the type of information that is being requested about the diagnosis. NOTE: The X12 278 implementation guide currently does not place any restrictions on specific LOINC codes that can be used. This value set is all of LOINC but it is expected that senders will use a specific set of LOINC codes.

X12 278 Diagnosis Type Value Set

This set of codes is used to identify the type of diagnosis that is being conveyed in the prior authorization.

X12 278 Follow Up Action Value Set

The complete set of codes that are used to indicate any follow-up actions that are allowed for a reject reason.

X12 278 Health Care Service Location Type Value Set

This set of codes identifies where services were, or may be, performed. The codes are taken from NUBC Bill Type and from CMS Place of Service codes.

X12 278 Reject Reason Value Set

The complete set of codes that are used to indicate the reason why something was rejected.

X12 278 Requested Service Type

This set of codes identifies what service is being requested. It is a combination of X12 Service Type codes, CPT (HCPCS I) and HCPCS II procedure code modifiers, ICD-9 Procedure codes, and ICD-10 Procedure codes.

X12 278 Review Descision Reason Codes

Codes used to identify the reason for the health care service review outcome.

Terminology: Code Systems

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

AHA NUBC Revenue Code System

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).

PAS Diagnosis Type

The type of diagnosis being conveyed in a prior authorization. This code is combined with the Diagnosis Code to produce the proper X12 code.

PAS Information Change Mode Code System

The mode by which a piece of information has changed.

PAS Supporting Info Type Code System

Types of supporting information for a Prior Authorization Claim.

X12 278 Follow Up Action Code System

The complete set of codes that are used to indicate any follow-up actions that are allowed for a reject reason.

X12 278 Reject Reason Code System

The complete set of codes that are used to indicate the reason why something was rejected.

Example: Example Instances

These are example instances that show what data produced and consumed by systems conforming with this implementation guide might look like

Homecare Authorization Bundle Example

An example of a Claim bundle requesting prior authorization of a home healthcare service.

Homecare Authorization Differential Update Bundle Example

An example of a Claim bundle changing elements of a previously sent prior authorization request.

Homecare Authorization Differential Update Example

An example of a Claim resource updating a prior authorization.

Homecare Authorization Example

An example of a Claim resource requesting prior authorization of a home healthcare service.

Homecare Authorization Update Bundle Example

An example of a Claim bundle updating a previously sent prior authorization request.

Homecare Authorizaion Update Example

An example of a Claim resource updating a prior authorization.

Submit Claim Insurance Example

Sample insurance for a prior authorization.

Submit Claim Insurer Example

A sample payor organization.

Medical Services Authorization Bundle Example

An example of a Claim bundle requesting Medical Services Reservation.

Medical Services Authorization Example

An example of a Claim resource requesting prior authorization of Medical Services Reservation.

Referral Authorization Bundle Example

An example of a Claim bundle requesting prior authorization of a referral.

Referral Authorization Example

An example of a Claim resource requesting prior authorization of a referral.

Referral Authorization Response Bundle Example

An example of a ClaimResponse bundle approving the authorization of a referral.

Referral Authorization Response Example

An example of a ClaimResponse giving approval for a referral.

Submit Claim Referral Practitioner Example

A sample practitioner who is being referred to.

Submit Claim Referral Request Example

A sample referral request that is the subject of a prior authorization.

Submit Claim Subscriber Example

Sample patient who is a subscriber of an insurance plan.

Submit Claim Requestor Example

A sample organization that is requesting a prior authorization.