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Uniform Structure and Coding Elements for Prior Authorization

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Basics

Uniform Structure and Coding Elements for Prior Authorization

1656
Ballot - Informative


FHIR Profile

White Paper (Balloted Informative)

Details

As a supplement to the Da Vinci Coverage Requirements Discovery (CRD), Documentation Templates and Rules (DTR), and Prior Authorization Support (PAS) FHIR implementation guides, this group will:

- Choose a topic item, services or domain(e.g. Imaging)].

- List industry requirements for documentation for the specific item/service/domain.

- Determine if there is existing support in FHIR for specific elements and code systems/value sets to describe the required documentation for the topic.

- Define required changes/enhancements to existing FHIR resources or code systems/value sets.

- Determine if the current version of USCDI supports the necessary concepts.

- Where necessary, submit request to ONC for inclusion of required concepts in the next version of USCDI.

- Where external code systems have gaps, work with the responsible organization to enhance LOINC, SNOMED, ICD-10, or HCPCS where appropriate.

- Create or expand existing value sets to include required codes from the appropriate code systems.

- Work with HL7 Cross-Group Projects Workgroup to enhance next version of US CORE profiles to support required data elements, code systems, and value sets.


The United States has one of the world’s most complex healthcare systems, with different organizations providing different types of care across geographic and clinical lines as well as with hundreds of separate payer organizations often with differing documentation requirements to justify coverage/payment. Providers can often feel overwhelmed by the differing and hard to access documentation requirements of the various health plans.

There are a number of benefits that could be recognized if required documentation elements were more clearly defined across payers. If required data elements are more clearly defined, there may be reduced provider burden by:

- Encouraging both provider and payer support for the defined elements

- More quickly developing support for payer specific requirements

- Validating/capturing required data elements for specific purposes (e.g. prior authorization)



Submit for first Informative Ballot - Target: 2022 Jan Ballot Complete Reconciliation - Target: 2022 May WGM Submit for 2nd Informative Ballot - Target: 2022 September Ballot Complete Reconciliation - Target: 2023 January WGM Informative Period - Target: 2024 January WGM Submit for Normative Ballot - Target: 2024 May WGM Receive ANSI Approval - Target: 2024 June Project End Date (all objectives have been met) - Target: 2024 July May 2023 WGM - review status for continuance or closure


https://confluence.hl7.org/display/DVP/Uniform+Structure+and+Coding+of+Elements+for+Prior+Authorization+PSS


1493 – Documentation Templates and Rules (Da Vinci) 1490 – Prior Authorization Support (Da Vinci) 1428 – FHIR Implementation Guide for Coverage Requirements Discovery (Da Vinci)

Clinical and Public Health Laboratories, Regulatory Agency, Standards Development Organizations (SDOs), Payors,Medical Imaging Service; Healthcare Institutions (hospitals, long term care, home care, mental health),Pharmaceutical; EHR, PHR; Equipment; Health Care IT; Clinical Decision Support Systems; Lab

Cigna


Uniform Structure and Coding Elements for Prior Authorization, Payer Uniformity, Superset of Payer Documentation Requirements, Common Elements


Yes

N/A

No


Organization & Realm

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

U.S.
People

Melanie Combs-Dyer



Financial Management Work Group

Payer/Provider Info Exchange Work Group

Status & Dates

Active

Active Project (Resources assigned to pjt)

09/24/2020

09/01/2025

2025 Sept WGM/Ballot

05/01/2025

2025 May WGM/Ballot

2024 Sept Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Release 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 2022 Jan Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Prior-Authorization Support (PAS), Release 1- US Realm
Approvals



Pending


Pending




System Info



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