StructureDefinition-pdex-priorauthorization

Sourcehl7.fhir.us.davinci-pdex#current:Da Vinci Payer Data Exchange (v4.0.1)
resourceTypeStructureDefinition
idpdex-priorauthorization
canonicalhttp://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
version2.0.0
statusdraft
publisherHL7 Financial Management Working Group
namePdexPriorAuthorization
titlePDex Prior Authorization
date2023-08-14T14:40:10+00:00
experimentaltrue
descriptionThe PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeExplanationOfBenefit
derivationconstraint
basehttp://hl7.org/fhir/StructureDefinition/ExplanationOfBenefit
Usages
Name Flags Card. Type Description & Constraints doco
. . ExplanationOfBenefit C ExplanationOfBenefit adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
. . . meta
. . . . Slices for profile 1 .. Slice: Unordered, Open by pattern:$this
. . . . . profile:supportedProfile 1..1 Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0
. . . Slices for extension Slice: Unordered, Open by value:url
. . . levelOfServiceType S 0..1 CodeableConcept A code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
Binding: todo ( required ): Codes specifying the level of service rendered. 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.

. . . status S
. . . type S
. . . use S Required Pattern: preauthorization
. . . patient S Reference (US Core Patient Profile)
. . . enterer S Reference (US Core Practitioner Profile | US Core PractitionerRole Profile)
. . . insurer S Reference (US Core Organization Profile)
. . . provider S Reference (US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)
. . . priority Binding: Process Priority Codes ( required )
. . . facility S Reference (US Core Location Profile)
. . . preAuthRefPeriod S ..1
. . . careTeam
. . . . provider S Reference (US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)
. . . insurance
. . . . coverage Reference (HRex Coverage Profile)
. . . item
. . . . Slices for extension Slice: Unordered, Open by value:url
. . . . itemTraceNumber S 0..* Identifier Uniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
. . . . preAuthIssueDate S 0..1 date The date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
. . . . preAuthPeriod S 0..1 Period The date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
. . . . previousAuthorizationNumber S 0..1 string A string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
. . . . administrationReferenceNumber S 0..1 string A string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
. . . . authorizedItemDetail S 0..1 (Complex) The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
. . . . authorizedProvider S 0..* (Complex) The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
. . . . category S Binding: todo ( required ): Codes identifying business groupings for health care services or benefits. 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.

. . . . productOrService Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS ( required )
. . . . encounter Reference (US Core Encounter Profile)
. . . . Slices for adjudication Slice: Unordered, Closed by pattern:category
. . . . . adjudication:All Slices Content/Rules for all slices
. . . . . . Slices for extension Slice: Unordered, Open by value:url
. . . . . . reviewAction S 0..1 (Complex) The details of the review action that is necessary for the authorization at the line level.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
. . . . . . category Binding: PDex Adjudication Category Discriminator ( required )
. . . . . adjudication:adjudicationamounttype S 0..*
. . . . . . category Binding: PDex Adjudication ( required )
. . . . . . amount S 1..
. . . . . adjudication:allowedunits S 0..1
. . . . . . category Fixed Value: As shown (allowed units)
. . . . . . . coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
. . . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: allowedunits
. . . . . . value S 1..
. . . . . adjudication:denialreason S 0..*
. . . . . . category Fixed Value: As shown (Denial Reason)
. . . . . . . coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
. . . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: denialreason
. . . . . . reason S 1.. Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes ( required )
. . . . . adjudication:consumedunits S 0..1
. . . . . . category Fixed Value: As shown (consumed units)
. . . . . . . coding 1..1 Coding Code defined by a terminology system
Fixed Value: (complex)
. . . . . . . . system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
. . . . . . . . code 1..1 code Symbol in syntax defined by the system
Fixed Value: consumedunits
. . . . . . value S 1..
. . . addItem
. . . . provider Reference (US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)
. . . Slices for adjudication S BackboneElement Slice: Unordered, Closed by pattern:category
. . . . adjudication:All Slices Content/Rules for all slices
. . . . . Slices for extension Slice: Unordered, Open by value:url
. . . . . reviewAction S 0..1 (Complex) The details of the review action that is necessary for the authorization for the entire request.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
. . . . . category S Binding: PDex Adjudication Category Discriminator ( required )
. . . . adjudication:adjudicationamounttype S 0..*
. . . . . category Binding: PDex Adjudication ( required )
. . . . . amount 1..
. . . . adjudication:denialreason S 0..*
. . . total
. . . . Slices for extension Slice: Unordered, Open by value:url
. . . . priorauth-utilization S 0..1 Quantity, Ratio An attribute to express the amount of a service or item that has been utilized
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
. . . . category S Prior Authorization utilization codes
Binding: Prior Authorization value categories ( extensible )

doco Documentation for this format

Produced 08 Sep 2023