Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot

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-ballot 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

## Artifacts Summary

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

### Global profiles

There are no Global profiles defined

### Behavior: Capability Statements

The following artifacts define the specific capabilities that different types of systems are expected to have in order to comply with this implementation guide. Systems conforming to this implementation guide are expected to declare conformance to one or more of the following capability statements.

EHR PAS Capabilities | Capabilities required for an EHR participating in a PAS Exchange.
Intermediary PAS Capabilities | Capabilities required for an Intermediary participating in a PAS Exchange.

### Behavior: Operation Definitions

These are custom operations that can be supported by and/or invoked by systems conforming to this implementation guide.

Search for a Prior Authorization Response by example | This operation is used to make a search for a Prior Authorization Response by example for a previously-submitted PreAuthorization. This Prior Authorization $inquire operation is a query-by-example that follows the X12 278 Inquiry rules. The only input parameter is the single Bundle resource with a PASClaimInquiry instance (along with other referenced resources) and the only output is a single Bundle with zero-to-many PASClaimInquiryResponses (and other referenced resources) or an OperationOutcome resource.
Submit a Prior Authorization Request for adjudication | This operation is used to submit a PreAuthorization Claim Request for adjudication as a Bundle containing the PASClaimRequest and other referenced resources for processing. The only input parameter is the single Bundle resource with a PASClaimRequest instance (along with other referenced resources) and the only output is a single Bundle with a PASClaimResponse (and other referenced resources) or an OperationOutcome resource. This is a variant of the FHIR Core Claim $submit operation.

### Structures: Logical Models

These define data models that represent the domain covered by this implementation guide in more business-friendly terms than the underlying FHIR resources.

PAS Metric Data | A logical model describing the information that should be captured by PAS implementers about every PAS invocation to support measures evaluating PAS implementation

### Structures: Abstract Profiles

These are profiles on resources or data types that describe patterns used by other profiles, but cannot be instantiated directly. I.e. instances can conform to profiles based on these abstract profiles but do not declare conformance to the abstract profiles themselves.

PAS Claim Base | PAS constraints on Claim resource that are common to both the request and the inquiry.
PAS Claim Response Base | PAS constraints on ClaimResponse resource that are common to both the request and the inquiry.
PAS Organization Base Profile | A base profile for organizations in PAS

### 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 | This profile defines constraints and extensions used when updating a previously submitted Claim instance. 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. 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. 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. 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. 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. 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`. 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`.
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 Document Reference | PAS constraints on US Core DocumentReference to require the document content to be included and not referenced externally.
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 Location Profile | A profile on US-Core location to allow for specifying where a practitioner is working at.
PAS Medication Request | PAS constraints on MedicationRequest resource mandating support for elements relevant to the prescriptions being requested on a prior authorization request
PAS Nutrition Order | PAS constraint on Nutrition Order resource for elements relevant to the ordering of nutrition 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 PractitionerRole | PAS constraints on PractitionerRole 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.
PAS Subscription | The profile for PAS subscription.
PAS Task | PAS constraints on Task resource that is used to request additional documentation for prior authorizations.

### Structures: Data Type Profiles

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

PAS Identifier | Constraints and extensions on Identifier allowing for a common datatype across all resource profiles.
PAS Quantity | Constraints and extensions on SimpleQuantity which restricts the units.
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.
AuthorizedProviderType | The type of provider who has been authorized to provide this item.
CalendarPattern | A code representing the specific days when a service is being requested
CareTeamClaimScope | A flag that indicates whether the care team applies to the entire claim or a single item.
CertificationEffectiveDate | The specific date or period within which this item's preauthorization became effective.
CertificationExpirationDate | The specific date or period within which this item's preauthorization expires.
CertificationIssueDate | The specific date or period within which this item's preauthorization was issued.
CertificationType | A code representing the type of certification being requested (UM02)
CommunicatedDiagnosis | A code representing the diagnosis that is the subject of the communication
ConditionCode | Information to supply various patient conditions.
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)
DocumentInformation | Information about the document being included such as the type, transmission method, and identifier.
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. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103
ErrorFollowupAction | A code representing what action must occur to resolve this error.
ErrorPath | The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element. STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element. Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value
HomeHealthCareInformation | Information needed for home health care requests.
IdentifierJurisdiction | An additional element that provides the assigning jurisdiction of the identifier (i.e. provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.
IdentifierSubDepartment | An additional element that provides a further subdivision within the organization granting the identifier.
InfoCancelledFlag | A flag indicating whether the piece of information was cancelled.
InfoChanged | A code indicating how the piece of information has changed.
ItemAuthorizedDetail | The details of what has been authorized for this item.
ItemAuthorizedProvider | The specific provider who has been authorized to provide this item.
ItemPreAuthIssueDate | The date when this item's preauthorization was issued.
ItemPreAuthPeriod | The date/period when this item's preauthorization is valid.
ItemRequestedServiceDate | The original date/period that was requested by the submitter for this item.
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
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.
RevenueCode | A revenue code that expresses what was approved which maps to X12 SV201
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.
ServiceLineNumber | A number that links the content being requested with the claim item number.

### 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).
Metric Data Source | A list of codes indicating the perspective from which metric data was captured
PAS Communication Medium Value Set | Types of channels that a communication request can be made
PAS Information Change Mode Value Set | The mode by which a piece of information has changed.
PAS LOINC Attachment Codes Value Set | This value set includes LOINC terms that can be sent by a payer as part of an HL7 attachment request for additional information. It has been curated by the HL7 Payer/Provider Information Exchange (PIE) Work Group. More information about using LOINC in HIPAA attachments and the source of this value set can be found at LOINC Attahments.
PAS PWK01 Attachment Report Type Code Value Set | In addition to using LOINC attachment codes, a payer may request for additional information from the provider to support a prior authorization request using X12's PWK01 Attachment Report Type Code. Note that the PWK01 codes will not be published in due to X12 IP restrictions.
PAS Supporting Info Type Value Set | Types of supporting information for a Prior Authorization Claim.
PAS Task Codes | The code for the task that is request additional information.
X12 278 CRC Condition Category | This set of codes identifies the category of a patient's condition.
X12 278 CRC Condition Code | This set of codes identifies a patient's conditions.
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.
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 Nutrition Enteral Formula Type | This set of codes identifies enteral formula codes.
X12 278 Nutrition Oral Diet Type | This set of codes identifies oral diet 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 Modifier Type | This set of codes identifies modifiers to the type of service being requested. It is a combination of CPT (HCPCS I) and HCPCS II procedure code modifiers. NOTE: HCPCS Level 1 Codes are the CPT codes so either code system could be used to send the codes. When receiving the codes from an X12 system, the system returned will be HCPCS even if it was initially sent as a CPT code.
X12 278 Requested Service Type | This set of codes identifies what service is being requested. For queries, if the query is not searching for a specific service type, the not-applicable data absent reason code can be used. It is a combination of X12 Service Type codes, CPT (HCPCS I) and HCPCS II procedure code modifiers, ICD-9 Procedure codes, ICD-10 Procedure codes, and NDC Drug codes. NOTE: HCPCS Level 1 Codes are the CPT codes so either code system could be used to send the codes. When receiving the codes from an X12 system, the system returned will be HCPCS even if it was initially sent as a CPT code.
X12 278 Review Decision 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.

PAS Temporary Codes | Codes temporarily defined as part of the PAS implementation guide. These will eventually migrate into an officially maintained terminology (likely either SNOMED CT or HL7's UTG code systems).

### Example: Example Instances

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

Additional Information Task Example | An example of a PAS Task requesting additional information.
Authorization Response with Practitioner Requestor Example | An example of a ClaimResponse where the requestor is a Practitioner.
Authorization Response with Practitioner Requestor and Additional Content Example | An example of a ClaimResponse where the requestor is a Practitioner.
Communication Request Example | A sample communication request asking for more information about a specific diagnosis.
Device Request Example | A sample device request for a wheelchair.
Encounter Example | An example of encounter details for a surgical admission request.
Error Response Bundle Example | An example of a ClaimResponse bundle with errors.
Error Response Example | An example of a ClaimResponse with errors.
Homecare Authorization Bundle Example | An example of a Claim bundle requesting prior authorization of a home healthcare service.
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 Authorization Update Example | An example of a Claim resource updating a prior authorization.
Invalid Request Response | An instance of an operation outcome showing how an invalid request would be handled.
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.
Medication Request Example | A sample medication request to prescribe a specific drug.
Nutrition Order Example | A sample nutrition order.
PAS Claim Inquiry Example | An example of a Claim resource used to search for prior authorizations that match the example.
PAS Claim Inquiry ResponseExample | An example of a ClaimResponse resource that is a response to a claims inquiry.
PAS Document Reference Example | An example of a DocumentReference conveying a procedure note.
PAS Inquiry Request Bundle Example | An example of a Claim bundle inquiring about prior authorizations.
PAS Inquiry Response Bundle Example | An example of a ClaimResponse bundle returning a response to a claims inquiry.
PAS Subscription Notification Parameters | An example of the parameters going back for a PAS subscription notification
PAS Subscription Notification example | An example of a PAS Subscription Notification
PAS Subscription example for a specific provider | An example of a PAS Subscription submission for a specific provider.
Pending Authorization Response with Practitioner Requestor Example | An example of a ClaimResponse where the requestor is a Practitioner and the response is pended.
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 Pending Authorization Response Bundle Example | An example of a ClaimResponse bundle with a pending authorization of a referral.
Rejection Response Bundle Example | An example of a ClaimResponse bundle showing the rejection of a request.
Rejection Response Example | An example of a ClaimResponse that is rejected.
Submit Claim Beneficiary Example | Sample patient who is a beneficiary of an insurance plan.
Submit Claim Insurance Example | Sample insurance for a prior authorization.
Submit Claim Insurer Example | A sample payor organization.
Submit Claim Referral Location Example | A sample location.
Submit Claim Referral Practitioner Example | A sample practitioner who is being referred to.
Submit Claim Referral Practitioner Role Example | A sample practitioner role instance.
Submit Claim Referral Request Example | A sample referral request that is the subject of a prior authorization.
Submit Claim Requestor Example | A sample organization that is requesting a prior authorization.
Submit Claim Subscriber Example | Sample patient who is a subscriber of an insurance plan.
Submit Claim Surgical Location Example | A sample location.
Submit Claim Surgical Practitioner Example | A sample practitioner who is being referred to.
Submit Claim Surgical Practitioner Role Example | A sample practitioner role instance.
Surgical Admission Request Bundle Example | An example of a Claim bundle requesting prior authorization of a surgical service.
Surgical Request Authorization Example | An example of a Claim resource requesting prior authorization of a surgical service.

### Other

These are resources that are used within this implementation guide that do not fit into one of the other categories.

PAS Subscription Topic | This is the subscription topic used for retrieving results from pended authorization requests.