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 2.0.1 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 Overview

Page standards status: Informative

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Complying with this implementation guide means complying with a number of profiles, extensions, value sets and custom search parameters. This page provides an overview of where this information can be found.

The FHIR artifacts used by PAS are organized according to whether the content developed as part of the US Core implementation guides or is Da Vinci-specific.

Artifact Lists

FHIR PAS-specific Artifacts

US Core

Additional information about the use of these artifacts can be found in the main specification.

These FHIR artifacts define the clinical data that can be submitted as part of a prior authorization submission and/or included as part of a prior authorization response using the Claim submit operation.

The artifacts are of four types:

• Profiles constrain FHIR resources to reflect PAS requirements
• Extensions define additional data elements that can be conveyed as part of a resource
• Code Systems define PAS-specific terminologies to be used in one or more of those profiles
• Value Sets define the specific subsets of both PAS-defined and other code systems that can be (or are recommended to be) used within one or more profile elements
• Operations which define the PAS-specific constraints on the Claim submit operation as well as a Claim inquiry operation.

Cross-Version Analysis

This is an R4 IG. None of the features it uses are changed in R4B, so it can be used as is with R4B systems. Packages for both R4 (hl7.fhir.us.davinci-pas.r4) and R4B (hl7.fhir.us.davinci-pas.r4b) are available.

Intellectual Property Statements

This publication includes IP covered under the following statements.

• HL7 Inc.
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  • Claim Type Codes: Bundle/ErrorResponseBundleExample, Bundle/HomecareAuthorizationBundleExample... Show 19 more, Bundle/HomecareAuthorizationDifferentialBundleExample, Bundle/HomecareAuthorizationUpdateBundleExample, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/PASClaimInquiryResponseBundleExample, Bundle/ReferralAuthorizationBundleExample, Bundle/ReferralAuthorizationResponseBundleExample, Bundle/SurgicalRequestBundleExample, Claim/HomecareAuthorizationDifferentialExample, Claim/HomecareAuthorizationExample, Claim/HomecareAuthorizationUpdateExample, Claim/MedicalServicesAuthorizationExample, Claim/PASClaimInquiryExample, Claim/ReferralAuthorizationExample, Claim/SurgicalAuthorizationRequestExample, ClaimResponse/ErrorResponseExample, ClaimResponse/PASClaimInquiryResponseExample, ClaimResponse/PractitionerRequestorResponseExample and ClaimResponse/ReferralAuthorizationResponseExample
• ISO Maintains the copyright on the country codes, and controls it's use carefully. For futher 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 96 more, AttachmentRequestCodes, AuthorizationNumber, CalendarPattern, CareTeamClaimScope, CertificationEffectiveDate, CertificationExpirationDate, CertificationIssueDate, CertificationType, ClaimInquiry, ClaimSubmit, CommunicatedDiagnosis, ConditionCode, ContentModifier, DaVinciPriorAuthorizationSupport, DeliveryPattern, DiagnosisRecordedDate, EPSDTIndicator, ErrorElement, ErrorFollowupAction, ErrorPath, HomeHealthCareInformation, IdentifierJurisdiction, IdentifierSubDepartment, InfoCancelledFlag, InfoChanged, ItemAuthorizedDetail, ItemAuthorizedProvider, ItemPreAuthIssueDate, ItemPreAuthPeriod, ItemRequestedServiceDate, ItemTraceNumber, LevelOfServiceCode, MetricDataSource, MilitaryStatus, NursingHomeLevelOfCare, NursingHomeResidentialStatus, PALineNumber, PASBeneficiary, PASClaim, PASClaimBase, PASClaimInquiry, PASClaimInquiryResponse, PASClaimResponse, PASClaimResponseBase, PASClaimUpdate, PASCommunicationRequest, PASCommunicationRequestMedium, PASCoverage, PASDeviceRequest, PASEHR, PASEncounter, PASIdentifier, PASInformationChangeMode, PASInquiryRequestBundle, PASInquiryResponseBundle, PASInsurer, PASIntermediary, PASLocation, PASMedicationRequest, PASMetricData, PASNutritionOrder, PASOrganization, PASPractitioner, PASPractitionerRole, PASRequestBundle, PASRequestor, PASResponseBundle, PASServiceRequest, PASSubscriber, PASSubscription, PASSupportingInfoType, PASTask, PASTaskCodes, PASTempCodes, PASTiming, PatientStatus, ProductOrServiceCodeEnd, RequestedService, 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
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  • 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 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 is an example set.
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  • Adjudication Value Codes: Bundle/ErrorResponseBundleExample, Bundle/PASClaimInquiryResponseBundleExample... Show 7 more, Bundle/ReferralAuthorizationResponseBundleExample, ClaimResponse/PASClaimInquiryResponseExample, ClaimResponse/PractitionerRequestorResponseExample, ClaimResponse/ReferralAuthorizationResponseExample, PASClaimInquiryResponse, PASClaimResponse and PASClaimResponseBase
  • Process Priority Codes: Bundle/HomecareAuthorizationBundleExample, Bundle/HomecareAuthorizationDifferentialBundleExample... Show 12 more, Bundle/HomecareAuthorizationUpdateBundleExample, Bundle/MedicalServicesAuthorizationBundleExample, Bundle/PASClaimInquiryBundleExample, Bundle/ReferralAuthorizationBundleExample, Bundle/SurgicalRequestBundleExample, Claim/HomecareAuthorizationDifferentialExample, Claim/HomecareAuthorizationExample, Claim/HomecareAuthorizationUpdateExample, Claim/MedicalServicesAuthorizationExample, Claim/PASClaimInquiryExample, Claim/ReferralAuthorizationExample and Claim/SurgicalAuthorizationRequestExample
• 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: AttachmentRequestCodes, CommunicationRequest/CommunicationRequestExample... Show 4 more, ContentModifier, PASTask, Task/AdditionalInformationTaskExample and X12278DiagnosisInformationType

Global Profiles

There are no Global profiles defined

IG Dependencies

This IG Contains the following dependencies on other IGs.

Package hl7.fhir.uv.extensions.r4#1.0.0 This IG defines the global extensions - the ones defined for everyone. These extensions are always in scope wherever FHIR is being used (built Sun, Mar 26, 2023 08:46+1100+11:00)

Package hl7.fhir.r4.examples#4.0.1 Example resources in the R4 version of the FHIR standard

Package hl7.fhir.uv.sdc#3.0.0 The SDC specification provides an infrastructure to standardize the capture and expanded use of patient-level data collected within an EHR. This includes two components: * Support more sophisticated questionnaire/form use-cases such as those needed for research, oncology, pathology and other clinical domains. *Support pre-population and auto-population of EHR data into forms/questionnaires for uses outside direct clinical care (patient safety, adverse event reporting, public health reporting, etc.). (built Tue, Mar 8, 2022 18:32+0000+00:00)

Package hl7.fhir.us.udap-security#0.1.0 This implementation guide describes how to extend OAuth 2.0 to support secure and scalable workflows for business-to-business (B2B) apps that implement the client credentials flow or authorization code flow. (built Fri, Aug 6, 2021 15:57+0000+00:00)

Package hl7.fhir.us.davinci-hrex#1.0.0 The Da Vinci Payer Health Record exchange (HRex) Framework/library specifies the FHIR elements used in multiple Da Vinci implementation guides. This includes FHIR profiles, functions, operations, and constraints on other specifications such as CDS-Hooks and other aspects of Da Vinci Use Cases that are common across more than a single use case. Da Vinci HRex Implementation Guide (IG) will make use of US Core profiles that are based on the FHIR R4 specification wherever practical. The HRex IG will use the HL7 FHIR Release 4/US Core STU3 specification as its base but will provide additional guidance and documentation to support implementations that follow the HL7 FHIR STU3/US Core STU2 and HL7 FHIR DSTU2/Argonaut specifications. The HRex profiles documented in this IG will be used to exchange data between providers systems (e.g. EHRs) and other providers, payers, and third-party applications where appropriate. In addition, exchanges from payer systems to providers, other payers, and third-party applications are supported by the HRex profiles and operations. HRex may define new extensions, profiles, value sets, constraints/extension to other specification (e.g. specific CDS-Hooks) that are specific Da Vinci requirements. Where appropriate these Da Vinci specific artifacts will be promoted for incorporation into the future versions of existing standards (e.g. R4 US Core profiles) and deprecated in this guide on publication in the updated standard. (built Wed, Mar 23, 2022 18:55+0000+00:00)

Package hl7.fhir.us.davinci-crd#2.0.0 Guidelines for conveying coverage requirements to clinicians when planning treatment (built Fri, Oct 20, 2023 14:17+0000+00:00)

Package hl7.fhir.uv.subscriptions-backport.r4#1.1.0 The Subscription R5 Backport Implementation Guide enables servers running versions of FHIR earlier than R5 to implement a subset of R5 Subscriptions in a standardized way. (built Wed, Jan 11, 2023 15:34+1100+11:00)