This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.2.0-ballot: STU 2 Ballot) based on FHIR (HL7® FHIR® Standard) R4. This version is a pre-release. The current official version is 2.1.0. For a full list of available versions, see the Directory of published versions

Artifacts Overview

Page standards status: Informative

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.

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.

Many of the profiles are based on US Core 7.0.0 while also declaring conformance with US Core 6.1.0 and 3.1.1. In some cases, the 7.0.0 and/or 6.1.0 releases introduce new "mustSupport" elements that are not mustSupport in 3.1.1. The intention of this implementation guide is NOT to move forward the timelines by which EHRs and/or payers must support USCDI 3 and 4 content. Rather, it is to allow seamless transition as systems start to support the newer US Core releases as systems start to bring them on stream. As such, clients and servers have no obligations with respect to elements that are newly mustSupport in 6.1.0 or 7.0.0 beyond "don't error if these elements are present" until such time as those systems claim conformance with the US Core release which introduces those elements as mustSupport. Once a system claims conformance to US Core 6.1.0 or 7.0.0, then the conformance expectations of those release of the US Core guide come into play.

Terminology Artifacts can be found on its own page.

Guide Artifacts

Capability Statements

• EHR PAS Capabilities - Required for EHRs participating in a PAS Exchange
• Intermediary PAS Capabilities - Required for Intermediaries (and/or Payors) participating in a PAS Exchange

Operation Definitions

• Submit a Prior Authorization Request for Adjudication - This operation is used to make a search for a Prior Authorization Response by example. 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.
• Search for a Prior Authorization Response by example - 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.

Metrics Logical Model

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

PAS Subsription Topic

• PAS Subscription Topic -

Profiles

Bundle Profiles

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

Abstract Resource Profiles

• 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.

Claim Profiles

• 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 Update - This profile defines constraints and extensions used when updating a previously submitted Claim instance.

ClaimResponse Profiles

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

Patient Profiles

• PAS Subscriber Patient - A patient who is the subscriber of an insurance plan.
• PAS Beneficiary Patient - A patient who is the beneficiary of an insurance plan.

Organization / Location Profiles

• PAS Organization Base - A base profile for organizations in PAS
• PAS Insurer Organization - An organization who provides insurance and is the receiver of a prior authorization request.
• PAS Requestor Organization - The organization who is making a prior authorization request.
• PAS Location - A profile on US-Core location to allow for specifying where a practitioner is working at.

Practitioner Profiles

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

Other Profiles

• 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 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 Device Request - PAS constraints on DeviceRequest resource mandating support for elements relevant to the devices being requested on a prior authorization request
• PAS Coverage - PAS constraints on Coverage resource mandating support for insurance elements relevant to the prior authorization request
• 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 Communication Request - PAS constraints on CommunicationRequest resource mandating support for elements relevant to the prior authorization response
• PAS Subscription - The profile for PAS subscription.
• PAS Task - PAS constraints on Task resource that is used to request additional documentation for prior authorizations.

Data Type Profiles

• 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.

Extensions

• AdministrationReferenceNumber
• AuthorizationNumber
• AuthorizedProviderType
• CalendarPattern
• CareTeamClaimScope
• CertificationEffectiveDate
• CertificationExpirationDate
• CertificationIssueDate
• CertificationType
• CommunicatedDiagnosis
• ConditionCode
• ContentModifier
• DeliveryPattern
• DiagnosisRecordedDate
• DocumentInformation
• EPSDTIndicator
• ErrorElement
• ErrorFollowupAction
• ErrorPath
• HomeHealthCareInformation
• IdentifierJurisdiction
• IdentifierSubDepartment
• InfoCancelledFlag
• InfoChanged
• ItemAuthorizedDetail
• ItemAuthorizedProvider
• ItemPreAuthIssueDate
• ItemPreAuthPeriod
• ItemRequestedServiceDate
• ItemTraceNumber
• LevelOfServiceCode
• MilitaryStatus
• NursingHomeLevelOfCare
• NursingHomeResidentialStatus
• PatientStatus
• ProductOrServiceCodeEnd
• RequestedService
• RevenueCode
• RevenueUnitRateLimit
• ReviewAction
• ReviewActionCode
• ServiceItemRequestType
• ServiceLineNumber

Examples

The following examples are present in this guide to show specific use cases:

• Referral Authorization with Accepted Response
• Homecare Authorization with an Update of the Authorization Request
• Medical Services Authorization
• Surgical Request Authorization
• Invalid Request Response
• Error Response
• Reject (DENY) Authorization
• Pending (PEND) Response
• Additional Information Task Example
• Subscription, Subscription Notification, and Claim Inquiry and a Claim Inquiry Response

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.

Global Profiles

There are no Global profiles defined