This Section describes the expected capabilities of the PDEX Server actor which is responsible for providing responses to the queries submitted by the PDEX Requestors. The complete list of FHIR profiles, RESTful operations, and search parameters supported by PDEX Servers are defined. PDEX Clients have the option of choosing from this list to access necessary data based on their local use cases and other contextual requirements.

This operation is used to return all the clinical information related to a single patient described in the resource or context on which this operation is invoked. The response is a bundle of type “searchset”. At a minimum, the patient resource(s) itself is returned, along with any other clinical (as defined by USCDI) resources that the server has that are related to the patient, and that are available for the given user. The server also returns whatever resources are needed to support the records - e.g., linked practitioners, medications, locations, organizations etc. It should be noted that the server may need to filter resources to exclude resource profiles that fall outside of the clinical context. For example, excluding Blue Button claims that use the ExplanationOfBenefit resource, while including PDex Prior Authorizations that use the same base resource.

The intended use for this operation is to provide a payer with access to the entire clinical record. The server SHOULD return at least all resources that it has that are in the patient compartment for the identified patient(s), and any resource referenced from those, including binaries and attachments. In the US Realm, at a minimum, the resources returned SHALL include all the data covered by the meaningful use common data elements as defined in the US Core Implementation Guide. The PDex Implementation Guide adds Pdex-Device, Pdex-MedicationDispense and Pdex-PriorAuthorization to the clinical resource set. Other applicable implementation guides may make additional rules about how much information that is returned.

The business/claim identifier of the Explanation of Benefit

The reference to the patient

Date of the service for the EOB. The service-date search parameter simplifies the search, since a client doesn’t need to know that. For inpatient and outpatient institutional EOB dates they need to search by billablePeriod.period.start, for a pharmacy EOB by item.servicedDate, and for a professional and non-clinician EOB - by item.servicedPeriod.period.start.

The type of the ExplanationOfBenefit

Returns dispensed prescriptions for a specific patient. NOTE: This Pdex SearchParameter definition extends the usage context of capabilitystatement-expectation extension to formally express implementer conformance expectations for these elements:

• multipleAnd
• multipleOr
• comparator
• modifier
• chain.

Status of the prescription dispense. NOTE: This SearchParameter definition extends the usage context of capabilitystatement-expectation extension to formally express implementer conformance expectations for these elements:

• multipleAnd
• multipleOr
• comparator
• modifier
• chain.

The HRex Coverage Profile defines the constraints for representing a member’s healthcare insurance information to the Payer. Coverage instances complying with this profile, sometimes together with the Patient which this profile references via beneficiary, allows a payer to identify a member in their system.

The PDex Device profile is provided to enable payers to record information about devices used by a member that may not have a UDI number. FHIR-29796 PDex Device uses base resource not US Core Implantable Device Profile. Pdex-Device enables payers to record non-implantable device data. CGP Voted on variance approval: Drew Torres/Eric Haas: 9-0-0

Prescription Medications dispensed by a pharmacy to a health plan member and paid for in full, or in part, by the health plan

The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members

Provenance is provided by the payer to identify the source of the information, whether the data came via a clinical record or a claim record and whether the data was subject to manual transcription or other interpretive transformation. This profile adds PayerSourceFormat as an extension on the entity base element.

Attribute that identifies the refill number of a prescription. e.g., 0, 1, 2, etc.

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

Attribute that expresses the amount of an item or service that has been consumed under the current prior authorization.

Attributes that identify the source record format from which data in the referenced resources was derived

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

The code describing the result of the review.

The Drug Listing Act of 1972 requires registered drug establishments to provide the Food and Drug Administration (FDA) with a current list of all drugs manufactured, prepared, propagated, compounded, or processed by it for commercial distribution. (See Section 510 of the Federal Food, Drug, and Cosmetic Act (Act) (21 U.S.C. § 360)). Drug products are identified and reported using a unique, three-segment number, called the National Drug Code (NDC), which serves as a universal product identifier for drugs. FDA publishes the listed NDC numbers and the information submitted as part of the listing information in the NDC Directory which is updated daily.

The information submitted as part of the listing process, the NDC number, and the NDC Directory are used in the implementation and enforcement of the Act.

Users should note:

Starting June 1, 2011, only drugs for which electronic listings (SPL) have been submitted to the FDA are included in the NDC Directory. Drugs for which listing information was last submitted to FDA on paper forms, prior to June 2009, are included on a separate file and will not be updated after June 2012.

Information regarding the FDA published NDC Directory can be found here

Users should note a few important items

• The NDC Directory is updated daily.
• The new NDC Directory contains ONLY information on final marketed drugs submitted to the FDA in SPL electronic listing files by labelers.
• The NDC Directory does not contain all listed drugs. The new version includes the final marketed drugs which listing information were submitted electronically. It does not include animal drugs, blood products, or human drugs that are not in final marketed form, such as Active Pharmaceutical Ingredients(APIs), drugs for further processing, drugs manufactured exclusively for a private label distributor, or drugs that are marketed solely as part of a kit or combination product or inner layer of a multi-level packaged product not marketed individually. For more information about how certain kits or multi-level packaged drugs are addressed in the new NDC Directory, see the NDC Directory Package File definitions document. For the FDA Online Label Repository page and additional resources go to: FDA Online Label Repository

Describes the various amount fields used when payers receive and adjudicate a claim. It includes the values defined in http://terminology.hl7.org/CodeSystem/adjudication, as well as those defined in the PDex Adjudication CodeSystem.

Used as the discriminator for adjudication.category and item.adjudication.category for the PDex Prior Authorization

The Value Set is a combination of three Code Systems: CPT (HCPCS I), HCPCS II procedure codes, and HIPPS rate codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files and the rate codes from the HIPPS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

Category I: These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

Category III: These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

Proprietary Laboratory Analyses (PLA) codes: Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form here

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

The Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers. Institutional providers use HIPPS codes on claims in association with special revenue codes. One revenue code is defined for each prospective payment system that requires HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44 (“HCPCS/rate”) on a paper UB-04 claims form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information. The additional information varies among HIPPS codes pertaining to different payment systems, but often provides information about the clinical assessment used to arrive at the code. Which positions of the code carry the case mix group information may also vary by payment systems.

Indicates the in network or out of network payment status of the claim.

The Value Set is a combination of three Code Systems: CPT (HCPCS I), HCPCS II procedure codes, and HIPPS rate codes. They are submitted by providers to payers to convey the specific procedure performed. Procedure Codes leverage US Core Procedure Codes composition.

The target set for this value set are the procedure codes from the CPT and HCPCS files and the rate codes from the HIPPS files.

The Current Procedural Terminology (CPT) code set, created and maintained by the American Medical Association, is the language of medicine today and the code to its future. This system of terminology is the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. CPT coding is also used for administrative management purposes such as claims processing and developing guidelines for medical care review. Each year, via a rigorous, evidence-based and transparent process, the independent CPT Editorial Panel revises, creates or deletes hundreds of codes in order to reflect current medical practice.

Designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

There are various types of CPT codes:

Category I: These codes have descriptors that correspond to a procedure or service. Codes range from 00100–99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These alphanumeric tracking codes are supplemental codes used for performance measurement. Using them is optional and not required for correct coding.

Category III: These are temporary alphanumeric codes for new and developing technology, procedures and services. They were created for data collection, assessment and in some instances, payment of new services and procedures that currently don’t meet the criteria for a Category I code.

Proprietary Laboratory Analyses (PLA) codes: Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses and can be either provided by a single (solesource) laboratory or licensed or marketed to multiple providing laboratories that are cleared or approved by the Food and Drug Administration (FDA)). This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

To obtain CPT, please see the license request form here

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

The Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers. Institutional providers use HIPPS codes on claims in association with special revenue codes. One revenue code is defined for each prospective payment system that requires HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44 (“HCPCS/rate”) on a paper UB-04 claims form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information. The additional information varies among HIPPS codes pertaining to different payment systems, but often provides information about the clinical assessment used to arrive at the code. Which positions of the code carry the case mix group information may also vary by payment systems.

Used as the discriminator for the types of supporting information for the PDEX Prior Authorization. Based on the CARIN IG for Blue Button� Implementation Guide.

Codes to define Prior Authorization requested, agreed and utilized amounts.

Agent role performed relating to referenced resource

Source Data formats used as the source for FHIR referenced record by the Payer.

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

X12, chartered by the American National Standards Institute for more than 40 years, develops and maintains EDI standards and XML schemas which drive business processes globally. X12’s diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

The X12 Claim Adjustment Reason Codes describe why a claim or service line was paid differently than it was billed. These codes are listed within an X12 implementation guide (TR3) and maintained by X12.

Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

Each RARC identifies a specific message as shown in the Remittance Advice Remark Code List. There are two types of RARCs, supplemental and informational. The majority of the RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by a CARC. The second type of RARC is informational; these RARCs are all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC.

External code lists maintained by X12 and external code lists maintained by others and distributed by WPC on behalf of the maintainer can be found here:

https://x12.org/codes

Click on the name of any external code list to access more information about the code list, view the codes, or submit a maintenance request. These external code lists were previously published on either www.wpc-edi.com/reference or www.x12.org/codes.

The Level II HCPCS codes, which are established by CMS’s Alpha-Numeric Editorial Panel, primarily represent items and supplies and non-physician services not covered by the American Medical Association’s Current Procedural Terminology-4 (CPT-4) codes; Medicare, Medicaid, and private health insurers use HCPCS procedure and modifier codes for claims processing. Level II alphanumeric procedure and modifier codes comprise the A to V range.

General information can be found here: https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo

Releases can be found here: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets

These files contain the Level II alphanumeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage and pricing data.

Health Insurance Prospective Payment System (HIPPS) rate codes represent specific sets of patient characteristics (or case-mix groups) health insurers use to make payment determinations under several prospective payment systems. Case-mix groups are developed based on research into utilization patterns among various provider types. For the payment systems that use HIPPS codes, clinical assessment data is the basic input. A standard patient assessment instrument is interpreted by case-mix grouping software algorithms, which assign the case mix group. For payment purposes, at least one HIPPS code is defined to represent each case-mix group. These HIPPS codes are reported on claims to insurers. Institutional providers use HIPPS codes on claims in association with special revenue codes. One revenue code is defined for each prospective payment system that requires HIPPS codes. HIPPS codes are placed in data element SV202 on the electronic 837 institutional claims transaction, using an HP qualifier, or in Form Locator (FL) 44 (“HCPCS/rate”) on a paper UB-04 claims form. The associated revenue code is placed in data element SV201 or in FL 42. In certain circumstances, multiple HIPPS codes may appear on separate lines of a single claim.

HIPPS codes are alpha-numeric codes of five digits. Each code contains intelligence, with certain positions of the code indicating the case mix group itself, and other positions providing additional information. The additional information varies among HIPPS codes pertaining to different payment systems, but often provides information about the clinical assessment used to arrive at the code. Which positions of the code carry the case mix group information may also vary by payment systems.

X12, chartered by the American National Standards Institute for more than 40 years, develops and maintains EDI standards and XML schemas which drive business processes globally. X12’s diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

Remittance Advice Remark Codes (RARCs) are used to provide additional explanation for an adjustment already described by a Claim Adjustment Reason Code (CARC) or to convey information about remittance processing.

Each RARC identifies a specific message as shown in the Remittance Advice Remark Code List. There are two types of RARCs, supplemental and informational. The majority of the RARCs are supplemental; these are generally referred to as RARCs without further distinction. Supplemental RARCs provide additional explanation for an adjustment already described by a CARC. The second type of RARC is informational; these RARCs are all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey information about remittance processing and are never related to a specific adjustment or CARC.

External code lists maintained by X12 and external code lists maintained by others and distributed by WPC on behalf of the maintainer, including the RARC codes. Can be found here:

https://x12.org/codes

Click on the name of any external code list to access more information about the code list, view the codes, or submit a maintenance request. These external code lists were previously published on either www.wpc-edi.com/reference or www.x12.org/codes.

Identifier Type

Describes the various amount fields used when payers receive and adjudicate a claim. It complements the values defined in http://terminology.hl7.org/CodeSystem/adjudication.

Used as the discriminator for the data elements in adjudication and item.adjudication

Identifier Type codes that extend those defined in http://terminology.hl7.org/CodeSystem/v2-0203 to define the type of identifier payers and providers assign to claims and patients

Describes the various status fields used when payers adjudicate a claim, such as whether the claim was adjudicated in or out of network, if the provider was contracted or non-contracted for the service

Claim Information Category - Used as the discriminator for supportingInfo

Codes used to define Prior Authorization categories

CodeSystem for types of role relating to the creation or communication of referenced resources

CodeSystem for source formats that identify what non-FHIR source was used to create FHIR record(s)

X12, chartered by the American National Standards Institute for more than 40 years, develops and maintains EDI standards and XML schemas which drive business processes globally. X12’s diverse membership includes technologists and business process experts in health care, insurance, transportation, finance, government, supply chain and other industries.

The X12 Claim Adjustment Reason Codes describe why a claim or service line was paid differently than it was billed. These codes are listed within an X12 implementation guide (TR3) and maintained by X12.

External code lists maintained by X12 and external code lists maintained by others and distributed by WPC on behalf of the maintainer can be found here:

https://x12.org/codes

Click on the name of any external code list to access more information about the code list, view the codes, or submit a maintenance request. These external code lists were previously published on either www.wpc-edi.com/reference or www.x12.org/codes.

Example of a US Core Patient Record for Payer 1

Example of a US Core Patient Record for Payer 2

Example of a US Core Patient Record for Payer 2

Example of a MedicationDispense from a Claim

Example of a Transmitter Provenance record for a bundle

Example of an author Provenance record displaying a practitioner’s organization as the author

Example of an author Provenance record displaying a practitioner’s organization as the author

Example of an author Provenance record displaying a sole practitioner as the author

Example of a payer being the source of the data

Example of provenance based on security group recommendations

Example of a PDex Provenance record for a PDF embedded or linked in a DocumentReference resource.

Example of a Transmitter Provenance record for a bundle

Example of a Custodian Provenance record for the contents of a bundle received from another payer

Example of a US Core DocumentReference with a linked PDF document. The document could also be embedded.

A simple bundle to demonstrate a provenance example

A bundle that returns Conditions with provenance using _revinclude=Provenance:target

Example of a Practitioner Record

Example of a Pharmacy Location Record

Example of a Device from a Claim

Example of an Encounter that has a provenance record received by Payer 1

Example of an Encounter that has a provenance record received by Payer 1

Example of an Encounter that has a provenance record received by Payer 2

Example of a Coverage for a Member

Health Plan Coverage for Prior Authorization

PDex Prior Authorization based on EOB Inpatient Example

Example of the Payer Organization

Example of the Payer Organization

Another Example of the Payer Organization

Another Example of the Payer Organization

Payer Data Exchange Server Capability Statement

Provider Organization Example 1

Provider Organization Example 1