Stream: Da Vinci
Topic: Prior Auth IG
Jason Walonoski (Apr 05 2019 at 18:10):
Is there any content to the Prior Auth IG other than this http://wiki.hl7.org/index.php?title=Da_Vinci_Prior_Authorization_FHIR_IG_Proposal
I'm looking for FHIR profiles and/or operation definitions and not just a high-level use-case description.
Lloyd McKenzie (Apr 05 2019 at 18:12):
I don't believe any work has started on IG content yet. That bit is just getting started.
Jason Walonoski (May 02 2019 at 15:15):
The Da Vinci Prior Auth Reference Implementation ---- written entirely without the benefit of an Implementation Guide ---- is available on GitHub (https://github.com/HL7-DaVinci/prior-auth) and is running in the cloud courtesy of HSPC at https://davinci-prior-auth.logicahealth.org/fhir
Sree (May 22 2019 at 01:07):
We are in the process of implementing the Prior Auth use case for connectathon. Is there any mapping documentation exist to map various FHIR resources to populate Claim FHIR resource? Are there any recommendation for minimal data requirements for Claim resource? What is the expectation about persisting ClaimResponse on EHR?
Jason Walonoski (May 22 2019 at 16:06):
@sreenivas mallipeddi At this time, no IG exists for Prior Auth. However, this a Reference Implementation you can look at. Beware that the Reference Implementation will need to be retrofitted to match the IG, once one gets written and published.
https://github.com/HL7-DaVinci/prior-auth
Lloyd McKenzie (May 22 2019 at 17:01):
@Jason Walonoski That's not totally true. The IG is here: https://build.fhir.org/ig/HL7/davinci-pas/
It just doesn't have a lot in it yet. We should have profiles starting to show up by the end of the week. (Obviously that's not an ideal time for Jacksonville, but the project has been on super-tight time-frames.)
Jason Walonoski (May 29 2019 at 15:04):
Please use this stream for discussion around the Prior Auth Track at the Jacksonville Connectathon.
Jason Walonoski (May 29 2019 at 16:05):
- What to do when the Prior Auth Claim is for a Procedure?
- What to do when the Prior Auth is rejected because more information is required?
- What to do when the Prior Auth result is not synchronous (e.g. human in the loop or takes N business days to resolve)?
Jason Walonoski (May 29 2019 at 16:09):
What to do when the Prior Auth Claim is for a Procedure?
POST a Claim to Claim/$submit where Claim.referral references a ServiceRequest with the ServiceRequest.category set as SNOMED 387713003 Surgical procedure and ServiceRequest.code is the Procedure code you want authorization for. Make sure the supporting resources are in the submitted Bundle.
Jason Walonoski (May 29 2019 at 16:12):
What to do when the Prior Auth is rejected because more information is required?
The ClaimResponse.outcome will be set to error and the ClaimResponse.disposition will have a message that more information is required. Optionally ClaimResponse.error elements will be present.
Jason Walonoski (May 29 2019 at 19:50):
Prior Auth Discussion around prior auth categories:
- DME (e.g. O2, CPAP)
- Speciality services (e.g. PT/OT)
- Procedure (e.g. cardiac cath, spinal injection)
- Medication
- Admission (from ER versus for elective procedure)
- Home health (e.g. nurse visits for CHF)
- Imaging (e.g. MRI for low back pain)
- Mental health (e.g. substance abuse)
- Labs (e.g. genetic testing such as BRCA1/BRCA2 for breast cancer)
Jason Walonoski (May 29 2019 at 19:53):
It would be good to have worked examples for each of those, or to determine what patterns are needed to cover these examples. E.g. When to use Claim.prescription versus Claim.referral versus Claim.item
Lloyd McKenzie (May 29 2019 at 20:28):
In answer to the third question, I assume the ClaimResponse would come back with an outcome of 'queued' and status of 'active'.
Agree on the need to have examples (or even profiles). Don't think that's going to happen for this ballot though.
@Jean Duteau FYI
Sree (May 30 2019 at 14:13):
sreenivas mallipeddi At this time, no IG exists for Prior Auth. However, this a Reference Implementation you can look at. Beware that the Reference Implementation will need to be retrofitted to match the IG, once one gets written and published.
https://github.com/HL7-DaVinci/prior-auth
Thank you
Lloyd McKenzie (Aug 28 2019 at 16:19):
For todays' connectathon
Lloyd McKenzie (Aug 28 2019 at 16:42):
https://build.fhir.org/ig/HL7/davinci-dtr/
Lloyd McKenzie (Aug 28 2019 at 16:42):
https://build.fhir.org/ig/HL7/davinci-pas
Viet Nguyen (Aug 28 2019 at 17:21):
Need to address which resource should be used to identify individuals and roles . This can be done with CareTeam, PractionerRole or within a resource (like MedicationRequest, where we want the ordering provider).
Lloyd McKenzie (Aug 28 2019 at 17:51):
More specifically Claim.careTeam vs. by the Encounter, Procedure, Observation, etc. pointed to by the Claim.
Nick Radov (Sep 14 2019 at 14:42):
https://build.fhir.org/ig/HL7/davinci-pas/
Gary Gryan (Sep 14 2019 at 14:42):
https://davinci-prior-auth.logicahealth.org/fhir/debug/Claim
https://confluence.hl7.org/pages/viewpage.action?pageId=58654789
Benjamin Langley (Nov 05 2019 at 13:16):
@Lloyd McKenzie the IG states "The patient.identifier is the member identifier that was submitted as the patient.identifier in the original claim."
However, identifier is not required on the patient resource (and I cannot find a PAS patient profile). So what happens if the patient in the Claim bundle does not include an identifier?
Lloyd McKenzie (Nov 05 2019 at 13:38):
Excellent question @Benjamin Langley. Can you submit a change request? We're going to have to discuss that.
Benjamin Langley (Nov 05 2019 at 14:21):
@Lloyd McKenzie will do. I don't have a GForge account yet so I just created one, waiting for administrator approval
Benjamin Langley (Nov 14 2019 at 12:49):
The PAS Bundle Profile (https://build.fhir.org/ig/HL7/davinci-pas/profile-pas-bundle.html) has a BackboneElement called ClaimOrResponse on Bundle.entry which is required (1...1). Is this just saying the bundle must have at least one Claim or ClaimResponse item? In the examples on the IG there is nothing called ClaimOrResponse in the bundle
Lloyd McKenzie (Nov 14 2019 at 13:20):
When we re-publish, that'll be slightly better rendered. ClaimOrResponse is the 'slice name' for an entry that's constrained to allow either a Claim or a ClaimResponse.
Benjamin Langley (Nov 21 2019 at 16:21):
@Lloyd McKenzie Walking through this ClaimOrResponse slice with Aegis and we wanted to verify - was the intent a PAS Bundle can only contain a single Claim or a single ClaimResponse (but not a ClaimResponse and a Claim)
Carie Hammond (Nov 21 2019 at 16:43):
@Richard Ettema Bringing this thread to your attention as you had looked at this IG for our Touchstone work and may be interested in the discussion.
Lloyd McKenzie (Nov 21 2019 at 20:36):
Yes. We use the same profile for both because we wanted to avoid creating needless profiles. However, you could comment and demand a separate Bundle profile for each.
Last updated: Apr 12 2022 at 19:14 UTC
