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

Plain Language Summary goes here

## Prior Authorization Implementation Guide Home Page

Official URL: http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas | Version: 2.2.0-ballot
IG Standards status: Trial-use | Maturity Level: 3 | Computable Name: DaVinciPriorAuthorizationSupport
Other Identifiers: OID:2.16.840.1.113883.4.642.40.24

> Welcome to the ballot for the STU 2.2 release of PAS.

> This release contains a number of changes requested by the implementer community. Most of them are non-signficant or backwards compatible changes, but there are a few that could at least be theoretically breaking for some implementations and there are a few that will be breaking for all implementations. A complete list of the changes for this ballot, as well as links to the tracker items that provide justification for them can be found here.

> There is also an open issue around the use of supplemental guides that has not been addressed in this ballot. Please see this Issues page for more discussion about this issue.

> IMPORTANT: The scope of this ballot is limited to the above changes and to feedback about the issues linked to above. While feedback can always be submitted against any content in the specification at any time, votes submitted against content that is outside the official scope of the ballot may be deemed 'not related' and therefore not able to support negative votes.

> This specification is currently published as a Standard for Trial Use (STU).

> Note that this implementation guide is intended to support mapping between FHIR and X12 transactions. To respect X12 intellectual property, all mapping and X12-specific terminology information will be solely published by X12 and made available in accordance with X12 rules - which may require membership and/or payment. Please see this Da Vinci External Reference page for details on how to get this mapping.

> There are many situationally required fields that are specified in the X12 TRN03 guide that do not have guidance in this Implementation Guide. All of these fields are marked as Must Support in this guide. However, due to licensing restrictions, implementers need to consult the X12 PAS guides to know the requirements for these fields.

> Several of the profiles will require use of terminologies that are part of X12 which we anticipate being made publicly available. At such time as this occurs, the implementation guide will be updated to bind to these as external terminologies.

### Overview

Prior authorization is a process commonly used by payer organizations to manage healthcare costs. However, the process of requesting and receiving prior authorizations can be slow and inefficient. The Administrative Simplification provisions of HIPAA mandate that the X12 278 Health Care Services Review Request for Review and Response be used for communicating prior authorization requests and responses. While few electronic health record (EHR) systems have implemented this interface, this functionality is often implemented as a portal solution and/or as a part of Practice Management and Revenue Cycle Management solutions. As a result, prior authorizations are often solicited by fax or by using payer-specific portals where clinicians re-key relevant information. Fax submission requires manual transcription on the payer side and may result in significant back-and-forth requesting additional information prior to a decision being made. Re-keying information is inefficient and can result in data entry errors.

This implementation guide strives to enable direct submission of prior authorization requests from EHR systems using a standard already widely supported by most EHRs - FHIR. To meet regulatory requirements, these FHIR interfaces will communicate with an intermediary who, when necessary, can convert the FHIR requests to the corresponding X12 instances prior to passing the requests to the payer. Responses are handled by a reverse mechanism (payer to intermediary as X12, then converted to FHIR and passed to the EHR). Direct submission of prior authorization requests from the EHR will reduce costs for both providers and payers. It will also result in faster prior authorization decisions which will lead to improved patient care and experience.

When combined with the Da Vinci Coverage Requirements Discovery (CRD) and Documentation Templates and Rules (DTR) implementation guides, direct submission of prior authorization requests will further increase efficiency by ensuring that authorizations are always sent when (and only when) necessary, and that such requests will almost always contain all relevant information needed to make the authorization decision on initial submission.

The implementation guide also defines capabilities around the management of prior authorization requests, including checking the status of a previously submitted request, updating a previously submitted request, and canceling a request.

A high-level summary of how all of these IGs will work together can be seen below:

Figure 1.1 - Interaction of CRD, DTR, and PAS

### CMS Exception

When using PAS under the CMS granted exception (Request Number: HL7 FHIR Exception #2021031001), the implementer(s) SHALL disregard any requirements in this Implementation Guide to translate the PAS FHIR Bundle into or out of the X12 278. The defined PAS FHIR request bundles SHALL be transmitted intact between the provider and payer. The PAS FHIR response bundles SHALL be transmitted intact between the payer and the provider. NOTE: This CMS exception has ended as of June 2024.

### CMS Enforcement Discretion

The Office of Burden Reduction and Health Informatics (OBRHI) National Standards Group (NSG) announced an enforcement discretion that they would not enforce the requirement to use the X12 278 for prior authorization if the covered entities were using the Fast Healthcare Interoperability Resources (FHIR) based Prior Authorization API as described in the CMS Interoperability and Prior Authorization final rule (CMS-0057-F). This allows the payer to return a prior authorization number for use in the X12 837 in coverage extension of the CRD and DTR IGs or as part of the all FHIR exchange of the Prior Authorization Response Bundle in the PAS IG.

When covered entities are operating under the enforcement discretion, the trading partners SHALL disregard any requirements in this Implementation Guide to translate the PAS FHIR Bundle into or out of the X12 278. The defined PAS FHIR request bundles SHALL be transmitted intact between the provider and payer. The PAS FHIR response bundles SHALL be transmitted intact between the payer and the provider.

### Content and Organization

This implementation guide (and the menu for it) is organized into the following sections:

- Background - Supporting informative pages that do not set conformance expectations
  - Reading this IG points to key pages in the FHIR spec and other source specifications that must be understood in order to understand this guide
  - Use Cases describes the intent of the implementation guide, gives examples of its use, and provides a high-level overview of expected process flow
  - Project and Participants gives a high-level overview of Da Vinci and identifies the individuals and organizations involved in developing this implementation guide
  - ePA Coordinators acknowledges that neither the payer nor provider systems involved in PAS are monolithic and shows how the various components of provider and payer systems might interact with "ePA Coordinator" systems to satisfy the requirements of this IG
- Specification - Pages that set conformance expectations
  - Conformance Expectations defines base language and expectations for declaring conformance with the guide
  - Request for Additional Info covers considerations around data access, protection, and similar concepts that apply to all implementations
  - HIPAA Regulations covers considerations around data access, protection, and similar concepts that apply to all implementations
  - Privacy, Safety, and Security covers considerations around data access, protection, and similar concepts that apply to all implementations
  - Metrics provides a logical model describing how to capture data that may be relevant to measuring or reporting on PAS use
- FHIR Artifacts
  - Overview introduces and provides links to the profiles, search parameters and other FHIR artifacts used in this implementation guide
  - Artifacts points to the complete list of artifacts defined in this guide
- Base Specifications - Quick links to the various specifications this guide derives from
- Support - Links to help with use of this guide
  - Discussion Forum is a place to ask questions about the guide, discuss potential issues, and search through prior discussions
  - Project Home includes information about project calls, agendas, past minutes, and instructions for how to participate
  - Implementer Support provides information about reference implementations, resources for testing, known errata, regulatory considerations, and practical implementation pathways
  - Project Dashboard shows new and historical issues that have been logged against the specification, proposed dispositions, unapplied changes, etc.
  - Propose a Change allows formal submission of requests for change to the specification. (Consider raising on the discussion forum first.)
  - Downloads allows download of this and other specifications, as well as other useful files

### Dependencies

> At present, PAS is based on FHIR R4. In addition, PAS is dependent on the US Core 3.1 (FHIR R4), US Core 6.1 (FHIR R4) and US Core 7.0 (FHIR R4) implementation guides. The first is supported for those systems limited to USCDI 1 capabilities, the second is for upcoming regulatory requirements mandating support for USCDI 3, and the last is to enable support for proposed regulations mandating support for USCDI 4. Wherever possible, Da Vinci profiles strive to comply with all three releases, simplifying implementation for those who will need to support varying regulatory expectations over time.

> In some situations, the payer community requires additional constraints or needs to profile resources that are not yet supported by US Core. In these cases, this IG does not derive from the US Core profiles, though it does align with them as much as possible. It is possible that certain PAS profiles and/or descriptive content may migrate to a future release of US Core, and in some cases, to the base FHIR standard.

In addition, this guide uses content from the following FHIR-related specifications and implementation guides:

- Subscriptions R5 Backport
- Da Vinci CRD

In addition, this guide also relies on a number of parent implementation guides:

Implementation Guide | Version(s) | Reason
--- | --- | ---
CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) | 2.1.0 |
Da Vinci - Coverage Requirements Discovery | 2.1.0 |
Da Vinci Health Record Exchange (HRex) | 1.1.0 | Imported by Da Vinci - Coverage Requirements Discovery (and potentially others)
FHIR Extensions Pack | 5.2.0 | Automatically added as a dependency - all IGs depend on the HL7 Extension Pack
5.1.0 | Imported by Da Vinci - Coverage Requirements Discovery (and potentially others)
FHIR R4 package : Core | 4.0.1 | Imported by HL7 Terminology (THO) (and potentially others)
HL7 Terminology (THO) | 6.5.0 | Automatically added as a dependency - all IGs depend on HL7 Terminology
6.2.0 | Imported by CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) (and potentially others)
6.1.0 | Imported by Da Vinci - Coverage Requirements Discovery (and potentially others)
5.5.0 | Imported by US Core (and potentially others)
5.0.0 | Imported by Subscriptions R5 Backport (and potentially others)
Public Health Information Network Vocabulary Access and Distribution System (PHIN VADS) | 0.12.0 | Imported by US Core (and potentially others)
SMART App Launch | 2.0.0 | Imported by US Core (and potentially others)
Structured Data Capture | 3.0.0 | Imported by US Core (and potentially others)
Subscriptions R5 Backport | 1.1.0 |
US Core | 7.0.0 | Needed for systems supporting USCDI v4
6.1.0 | Needed for systems supporting USCDI v3
3.1.1 | Needed for systems supporting USCDI v1
Value Set Authority Center (VSAC) | 0.21.0 | Imported by CARIN Consumer Directed Payer Data Exchange (CARIN IG for Blue Button®) (and potentially others)
0.19.0 | Imported by Da Vinci Health Record Exchange (HRex) (and potentially others)
0.18.0 | Imported by US Core (and potentially others)

This implementation guide defines additional constraints and usage expectations above and beyond the information found in these base specifications.

### Intellectual Property Considerations

This implementation guide and the underlying FHIR specification are licensed as public domain under the FHIR license. The license page also describes rules for the use of the FHIR name and logo.

There are a number of X12 codes that are used in the examples in this Implementation Guide. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

This publication includes IP covered under the following statements.

- "Material on this site is the copyrighted property of the United States Postal Service® (Postal Service™). All rights reserved. The information and images presented here may not under any circumstances be reproduced or used without prior written permission. Users may view and download material from this site only for the following purposes: (a) for personal, non-commercial home use; (b) where the materials clearly state that these materials may be copied and reproduced according to the terms stated in those particular pages; or (c) with the express written permission of the Postal Service. In all other cases, you will need written permission from the Postal Service to reproduce, republish, upload, post, transmit, distribute or publicly display material from this Web site. Users agree not to use the site for sale, trade or other commercial purposes. Users may not use language that is threatening, abusive, vulgar, discourteous or criminal. Users also may not post or transmit information or materials that would violate rights of any third party or which contains a virus or other harmful component. The Postal Service reserves the right to remove or edit any messages or material submitted by users."For more information, see https://about.usps.com/who/legal/terms-of-use.htm .
  Show Usage
  - USPS State Codes: Bundle/ErrorResponseBundleExample, Bundle/PASClaimInquiryResponseBundleExample... Show 4 more, Bundle/ReferralAuthorizationBundleExample, Bundle/RejectionResponseBundleExample, Claim/ReferralAuthorizationExample and IdentifierJurisdiction
- ISO maintains the copyright on the country codes, and controls its use carefully. For further details see the ISO 3166 web page: https://www.iso.org/iso-3166-country-codes.html
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  - ISO 3166-1 Codes for the representation of names of countries and their subdivisions — Part 1: Country code: AHANUBCRevenueCodes, AdministrationReferenceNumber... Show 102 more, AuthorizationNumber, AuthorizedProviderType, CalendarPattern, CareTeamClaimScope, CertificationEffectiveDate, CertificationExpirationDate, CertificationIssueDate, CertificationType, ClaimInquiry, ClaimSubmit, CommunicatedDiagnosis, ConditionCode, ContentModifier, DaVinciPriorAuthorizationSupport, DeliveryPattern, DiagnosisRecordedDate, DocumentInformation, EPSDTIndicator, ErrorElement, ErrorFollowupAction, ErrorPath, HomeHealthCareInformation, IdentifierJurisdiction, IdentifierSubDepartment, InfoCancelledFlag, InfoChanged, ItemAuthorizedDetail, ItemAuthorizedProvider, ItemPreAuthIssueDate, ItemPreAuthPeriod, ItemRequestedServiceDate, ItemTraceNumber, LevelOfServiceCode, MetricDataSource, MilitaryStatus, NursingHomeLevelOfCare, NursingHomeResidentialStatus, PASBeneficiary, PASClaim, PASClaimBase, PASClaimInquiry, PASClaimInquiryResponse, PASClaimResponse, PASClaimResponseBase, PASClaimUpdate, PASCommunicationRequest, PASCommunicationRequestMedium, PASCoverage, PASDeviceRequest, PASDocumentReference, PASEHR, PASEncounter, PASIdentifier, PASInformationChangeMode, PASInquiryRequestBundle, PASInquiryResponseBundle, PASInsurer, PASIntermediary, PASLOINCAttachmentCodesValueSet, PASLocation, PASMedicationRequest, PASMetricData, PASNutritionOrder, PASOrganization, PASPWK01AttachmentReportTypeCodeValueSet, PASPractitioner, PASPractitionerRole, PASQuantity, PASRequestBundle, PASRequestor, PASResponseBundle, PASServiceRequest, PASSubscriber, PASSubscription, PASSubscriptionTopic, PASSupportingInfoType, PASTask, PASTaskCodes, PASTempCodes, PASTiming, PatientStatus, ProductOrServiceCodeEnd, RequestedService, RevenueCode, RevenueUnitRateLimit, ReviewAction, ReviewActionCode, ServiceItemRequestType, ServiceLineNumber, X12278ConditionCategory, X12278ConditionCode, X12278DiagnosisCodes, X12278DiagnosisInformationType, X12278DiagnosisType, X12278FollowUpActionCodes, X12278LocationType, X12278NutritionEnteralFormulaType, X12278NutritionOralDietType, X12278RejectReasonCodes, X12278RequestedServiceModifierType, X12278RequestedServiceType and X12278ReviewDecisionReasonCode
- Licensing information can be found here These codes are listed within the UB-04 Data Specifications Manual. The Official UB-04 Data Specifications Manual, copyrighted by the American Hospital Association, is the only official source of UB-04 billing information adopted by the National Uniform Billing Committee. No other publication—governmental or private/commercial—can be considered authoritative. The AHA wants to make you aware that the use of codes, descriptions, or any other content contained in the manual to be used in a software application, publication, or any other derivative work must be properly licensed by the AHA. If your organization uses or intends to use any of the codes or other related content from the manual in this manner, please contact the AHA’s licensing manager, Tim Carlson, at 312.893.6816 or tcarlson@aha.org
  Show Usage
  - AHA NUBC Patient Discharge Status Codes: Bundle/SurgicalRequestBundleExample and Encounter/SurgicalEncounterExample
  - AHA NUBC Point of Origin for Non-newborn: Bundle/SurgicalRequestBundleExample and Encounter/SurgicalEncounterExample
  - AHA NUBC Priority (Type) of Admission or Visit: Bundle/SurgicalRequestBundleExample and Encounter/SurgicalEncounterExample
  - AHA NUBC Revenue Codes: AHANUBCRevenueCodes, ClaimResponse/PractitionerRequestorAdditionalContentResponseExample, PASClaimBase and RevenueCode
  - AHA NUBC Type Of Bill Codes: PASClaimBase and X12278LocationType
- The Centers for Medicare & Medicaid Services (CMS) maintain MS-DRGs used throughout the US health care industry. The CMS MS-DRGs are free to use without restriction.
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  - Medicare Severity Diagnosis Related Groups (MS-DRGs): CommunicatedDiagnosis, PASClaimBase and X12278DiagnosisCodes
- The UCUM codes, UCUM table (regardless of format), and UCUM Specification are copyright 1999-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. https://ucum.org/trac/wiki/TermsOfUse
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  - Unified Code for Units of Measure (UCUM): Bundle/ReferralAuthorizationBundleExample, MedicationRequest/MedicationRequestExample and ServiceRequest/ReferralRequestExample
- This CodeSystem is not copyrighted.
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  - C4BB Identifier Type Code System: PASInsurer, PASOrganization and PASRequestor
- This material contains content from LOINC. LOINC is copyright © 1995-2020, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license. LOINC® is a registered United States trademark of Regenstrief Institute, Inc.
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  - LOINC: Bundle/ReferralAuthorizationBundleExample, CommunicationRequest/CommunicationRequestExample... Show 5 more, ContentModifier, DocumentReference/DocumentReferenceExample, PASLOINCAttachmentCodesValueSet, Task/AdditionalInformationTaskExample and X12278DiagnosisInformationType
- This material derives from the HL7 Terminology (THO). THO is copyright ©1989+ Health Level Seven International and is made available under the CC0 designation. For more licensing information see: https://terminology.hl7.org/license.html
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  - Adjudication Value Codes: Bundle/PASClaimInquiryResponseBundleExample, Bundle/PASSubscriptionNotification... Show 11 more, Bundle/ReferralAuthorizationResponseBundleExample, Bundle/ReferralPendingAuthorizationResponseBundleExample, Bundle/RejectionResponseBundleExample, ClaimResponse/PASClaimInquiryResponseExample, ClaimResponse/PractitionerRequestorAdditionalContentResponseExample, ClaimResponse/PractitionerRequestorPendingResponseExample, ClaimResponse/PractitionerRequestorResponseExample, ClaimResponse/RejectionResponseExample, PASClaimInquiryResponse, PASClaimResponse and PASClaimResponseBase
  - Claim Type Codes: Bundle/ErrorResponseBundleExample, Bundle/HomecareAuthorizationBundleExample... Show 22 more, Bundle/HomecareAuthorizationUpdateBundleExample, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/PASClaimInquiryResponseBundleExample, Bundle/PASSubscriptionNotification, Bundle/ReferralAuthorizationBundleExample, Bundle/ReferralAuthorizationResponseBundleExample, Bundle/ReferralPendingAuthorizationResponseBundleExample, Bundle/RejectionResponseBundleExample, Bundle/SurgicalRequestBundleExample, Claim/HomecareAuthorizationExample, Claim/HomecareAuthorizationUpdateExample, Claim/MedicalServicesAuthorizationExample, Claim/PASClaimInquiryExample, Claim/ReferralAuthorizationExample, Claim/SurgicalAuthorizationRequestExample, ClaimResponse/ErrorResponseExample, ClaimResponse/PASClaimInquiryResponseExample, ClaimResponse/PractitionerRequestorAdditionalContentResponseExample, ClaimResponse/PractitionerRequestorPendingResponseExample, ClaimResponse/PractitionerRequestorResponseExample and ClaimResponse/RejectionResponseExample
  - Coverage Class Codes: PASCoverage
  - DataAbsentReason: ItemAuthorizedDetail, PASClaimBase... Show 5 more, PASClaimResponseBase, PASDeviceRequest, PASServiceRequest, ProductOrServiceCodeEnd and X12278RequestedServiceType
  - Example Related Claim Relationship Codes: Bundle/HomecareAuthorizationUpdateBundleExample, Claim/HomecareAuthorizationUpdateExample and PASClaimUpdate
  - Operation Outcome Codes: PASMetricData
  - Process Priority Codes: Bundle/ErrorResponseBundleExample, Bundle/HomecareAuthorizationBundleExample... Show 13 more, Bundle/HomecareAuthorizationUpdateBundleExample, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/PASClaimInquiryResponseBundleExample, Bundle/ReferralAuthorizationBundleExample, Bundle/RejectionResponseBundleExample, Bundle/SurgicalRequestBundleExample, Claim/HomecareAuthorizationExample, Claim/HomecareAuthorizationUpdateExample, Claim/MedicalServicesAuthorizationExample, Claim/PASClaimInquiryExample, Claim/ReferralAuthorizationExample and Claim/SurgicalAuthorizationRequestExample
  - SubscriberPolicyholder Relationship Codes: Bundle/HomecareAuthorizationBundleExample, Bundle/HomecareAuthorizationUpdateBundleExample... Show 6 more, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/PASClaimInquiryResponseBundleExample, Bundle/ReferralAuthorizationBundleExample, Bundle/SurgicalRequestBundleExample and Coverage/InsuranceExample
  - identifierType: Bundle/ErrorResponseBundleExample, Bundle/HomecareAuthorizationBundleExample... Show 15 more, Bundle/HomecareAuthorizationUpdateBundleExample, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/PASClaimInquiryResponseBundleExample, Bundle/PASSubscriptionNotification, Bundle/ReferralAuthorizationBundleExample, Bundle/ReferralAuthorizationResponseBundleExample, Bundle/ReferralPendingAuthorizationResponseBundleExample, Bundle/RejectionResponseBundleExample, Bundle/SurgicalRequestBundleExample, PASBeneficiary, PASCoverage, PASSubscriber, Patient/BeneficiaryExample and Patient/SubscriberExample
  - ActCode: Bundle/SurgicalRequestBundleExample and Encounter/SurgicalEncounterExample
- Used by permission of HL7 International, all rights reserved Creative Commons License
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  - US Core DocumentReferences Category Codes: Bundle/ReferralAuthorizationBundleExample and DocumentReference/DocumentReferenceExample