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.

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.

A base profile for organizations in PAS

A patient who is the beneficiary of an insurance plan.

PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request

PAS constraints on Claim resource when submitting an inquiry for existing authorizations.

PAS constraints on Claim resource mandating support for elements relevant to the response of an inquiry for details of previous authorizations.

PAS constraints on Claim resource mandating support for elements relevant to the response of a prior authorization request

PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request

PAS constraints on CommunicationRequest resource mandating support for elements relevant to the prior authorization response

PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request

PAS constraints on DeviceRequest resource mandating support for elements relevant to the devices being requested on a prior authorization request

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

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

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

An organization who provides insurance and is the receiver of a prior authorization request.

PAS constraints on MedicationRequest resource mandating support for elements relevant to the prescriptions being requested on a prior authorization request

PAS constraints on Practitioner resource mandating support for elements relevant to the care team involved in a prior authorization request

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

The organization who is making a prior authorization request.

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

PAS constraints on ServiceRequest resource mandating support for elements relevant to the generic services being requested on a prior authorization request

A patient who is the subscriber of an insurance plan.

Constraints and extensions on Identifier allowing for a common datatype across all resource profiles.

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

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

A string assigned by the UMO to an authorized review outcome associated with this service item.

A code representing the specific days when a service is being requested

A flag that indicates whether the care team applies to the entire claim or a single item.

The date/period when this item’s preauthorization is valid.

The date/period by which the item that is pre-authorized must be completed.

The date/period when this item’s preauthorization was issued.

A code representing the type of certification being requested (UM02)

A code representing the diagnosis that is the subject of the communication

A code representing a modifier of the content being requested

A code representing the specific delivery of a service being requested

The date that a diagnosis was recorded. (HIxx-4)

An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

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

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

An additional element that provides the jurisdiction of the identifier (i.e. state driver’s license) so that it does not need to be mapped from the identifier system.

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

A flag indicating whether the piece of information was cancelled.

A code indicating how the piece of information has changed.

The date/period by which the item that is pre-authorized must be completed.

The details of what has been authorized for this item if different from what was requested.

The specific provider who has been authorized to provide this item.

The date when this item’s preauthorization was issued.

The date/period when this item’s preauthorization is valid.

Uniquely identifies this claim item. (2000F-TRN)

A code specifying the level of service being requested (UM06)

A patient’s military status.

A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

A code specifying the status of a nursing home resident at the time of service. (SV209)

A code representing the status of the patient when being admitted

Used to provide the last code in a series of codes for the service being requested.

The details of the service being requested.

The limit on the rate per unit of revenue for hospital accomodation. (SV206)

The details of the review action that is necessary for the authorization.

The code describing the result of the review.

A code that identifies the type of service being requested.

A number that links the content being requested with the claim item number.

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).

The mode by which a piece of information has changed.

Types of supporting information for a Prior Authorization Claim.

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.

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.

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

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

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.

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

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.

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, 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.

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

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).

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

The mode by which a piece of information has changed.

Types of supporting information for a Prior Authorization Claim.

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

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

Sample patient who is a beneficiary of an insurance plan.

A sample communication request asking for more information about a specific diagnosis.

A sample device request for a wheelchair.

An example of encounter details for an admission request.

An example of a ClaimResponse bundle with errors.

An example of a ClaimResponse with errors.

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

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

An example of a Claim resource updating a prior authorization.

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

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

An example of a Claim resource updating a prior authorization.

Sample insurance for a prior authorization.

A sample payor organization.

An example of a Claim bundle requesting Medical Services Reservation.

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

A sample medication request to prescribe a specific drug.

An example of a Claim bundle inquiring about prior authorizations.

An example of a Claim resource used to inquire for prior authorizations that match the example.

An example of a ClaimResponse bundle returning a response to a claims inquiry.

An example of a ClaimResponse resource that is a response to a claims inquiry.

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

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

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

An example of a ClaimResponse giving approval for a referral.

A sample practitioner who is being referred to.

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

Sample patient who is a subscriber of an insurance plan.

A sample organization that is requesting a prior authorization.