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Authorization Support (Da Vinci Pjt; PSS In Confluence)

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Basics

Authorization Support (Da Vinci Pjt; PSS In Confluence)

1490
Ballot - STU to Normative


FHIR Implementation Guide; FHIR Profile

Implementation Guide

Details

A FHIR-based B2B process to allow implementers to use existing IT infrastructure resources for exchanging prior authorization. Existing business agreements can also be reused.

The goal is to define FHIR based services to enable provider, at point of service, to request authorization (including all necessary clinical information to support the request) and receive immediate authorization.

The assumption is that this use case will leverage the ASC X12N 278 and 275 for compliance with HIPAA.

Clearinghouses can continue to route and translate data as appropriate.

The project will investigate the ability to enable a translation layer to convert FHIR resources to HIPAA format and from HIPAA format back to FHIR.

This PSS builds on existing or in process implementation guides for the automation of coverage discovery (Coverage Requirements Discovery - CRD), definition of documentation and payer rules (Documentation Templates and Payer Rules) access to provider information (e Clinical Data Exchange - eCDX) and the e Health Record Framework (eHRx).

This project will define specific triggers and exchange methods (CDS Hooks, Push, etc.), use of other interoperability 'standards' (e.g. SMART on FHIR, CQL) and specific use of FHIR resources to effectively exchange payer information regarding the services that need authorization for coverage.

This project will reference, where possible the "standards" defined by the electronic Health Record exchange (eHRx) Framework Implementation Guide which in turn will utilize prior work from Argonaut, US Core and QI Core effort for FHIR DSTU2, STU3, and R4. The following diagram depicts the anticipated scope of the eHRx Framework IG.

The ultimate goal is to support the request, collection of existing information, solicitation of addition information (where required), packaging and exchange of provider information on a specific patient for satisfy the requirements for payer authorization for specific services using technology that supports FHIR DSTU2, STU3, and R4 releases of the FHIR standard.

This project will not include mapping to X12 standards and code sets - but this step is essential to the end-to-end workflow


Providers need the ability, in clinical workflow, to easily identify the need for payer authorizations, assemble necessary information, identify and supply missing information and submit it to the payer electronically. Payers should be able to respond to a number of requests for authorization in "real time" to allow the provider to move forward with treatment as soon as possible. This PSS builds on existing or in process implementation guides for the automation of coverage discovery (Coverage Requirements Discovery – CRD), definition of documentation and payer rules (Documentation Templates and Payer Rules) access to provider information (e Clinical Data Exchange - eCDX) and the e Health Record Framework (eHRx). Currently, no FHIR implementation guide exists to standardize the method of requesting, validating, soliciting, packaging and exchanging (request, response) information required for payer authorizations. This implementation guide will provide a standard for adoption by both providers and payers for the exchange of information necessary for authorization of services by a payer.



Standard For Trial Use (First Ballot Cycle) - Target: 2019 May Ballot Complete STU Reconciliation - Target: 2019 Aug Request STU Publication - Target: 2019 Sept WGM Submit for STU 2 Ballot (Second Ballot Cycle) - Target: 2020 May Ballot Complete STU 2 Reconciliation - Target: 2020 Aug Request STU 2 Publication - Target: 2020 Sept WGM STU 2 Period - Target: 2020 Sept -2022 Sept Submit for Normative Ballot - Target: 2022 May Ballot Complete Normative Reconciliation - Target: 2022 Sept WGM Submit Publication Request - Target: 2022 Oct Project End Date (all objectives have been met) - Target: 2022 Dec


https://confluence.hl7.org/display/FM/PSS+for+Prior-Authorization+Support HTTP://confluence.hl7.org/pages/viewpage.action?pageId=39158184


Coverage Requirements Discovery Documentation Templates and Rules

Clinical and Public Health Laboratories, Immunization Registries, Quality Reporting Agencies, Regulatory Agency, Standards Development Organizations (SDOs), Payors,Medical Imaging Service; Healthcare Institutions (hospitals, long term care, home care, mental health),Health Care IT; Clinical Decision Support Systems; Lab

1) Cerner 2) Cambia

None

Authorization Support, Prior Authorization, Da Vinci

N/A

Yes

N/A

No

2026 March: TSC approved an STU Publication Request for HL7 FHIR® Implementation Guide: Prior-Authorization Support (PAS), Edition 2.2 - US Realm 2024 December: TSC approved Unballoted STU Update Publication Request for HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Edition 2.1 - US Realm 2022 November: TSC approved STU Extension Request for Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.1.0: STU 1.1) for one year 2021 December: TSC approved Unballoted STU Update Publication Request for Da Vinci Prior Authorization Support (PAS) FHIR IG and Out of Cycle Ballot Request for HL7 FHIR Implementation Guide: ePayer Data Exchange (ePDx), Release 2 - US Realm and HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Release 2- US Realm 2020 Dec: TSC Approved STU Publication Request for HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Release 1- US Realm for 2 years. Other Stakeholders, Vendors, Providers: Other: Federal Healthcare Agencies (e.g. CMS), Providers (e.g. Physicians), Clearinghouses
Organization & Realm

Realm Specific - Enter "U.S." or name of HL7 Affiliate below

U.S.
People

Robert Dieterle, Viet Nguyen



Financial Management Work Group

Payer/Provider Info Exchange Work Group

Status & Dates

Active

STU - Reconcile

01/24/2019

05/01/2028

2028 May WGM/Ballot

05/15/2028

2028 May WGM/Ballot

2025 Sep Ballot Cycle Info: STU Ballot Results: Did not meet basic vote requirements. 29 Negatives to reconcile Document Name: HL7 FHIR® Implementation Guide: Prior-Authorization Support (PAS), Edition 2 - US Realm 2022 May Ballot Cycle Info: STU Ballot Results: Did not meet basic vote requirements. 54 Negatives to reconcile Document Name: * HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Release 2 - US Realm (See Jira Ballot Dashboard) 2019 Sept Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 45 Negatives to reconcile Document Name: HL7 FHIR® Implementation Guide: Prior-Authorization Support (PAS), Release 1- US Realm 2019 May Ballot Cycle Info: STU Ballot results: Postponed Document Name: HL7 FHIR Implementation Guide: Authorization, Release 1- US Realm
Approvals

03/04/2019


Received


All Received




System Info



View Ballot Items (with NIBs)



04/09/2026

Anne Wizauer
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