Claim $submit-preauthorization

Submit a a request for prior authorization of a claim.

Request Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
identifier
required, object

A persistent identifier for the bundle that won't change as a bundle is copied from server to server.

system
string

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
timestamp
required, string

The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

entry
required, [Claim, Patient, MedicationRequest, ServiceRequest, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, DocumentReference, Other]

An array of FHIR resources. At a minimum, a Claim Request should include the following entries:

  • Claim - the main prior auth request resource
  • Patient - the patient the claim is about
  • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
  • Coverage - the patient's insurance

Additional resources such as MedicationRequest or ServiceRequest may also be included to communicate additional information about the claim.

Any of:

An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

resource
required, object

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

resourceType
required, string

Identifies the type of the resource

Value: Claim
identifier
required, [object]

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

status
required, string

The status of the resource instance.

Value: active
type
required, object

Type of claim. Example Codes

The recommended system is http://terminology.hl7.org/CodeSystem/claim-type. Typical values include

  • pharmacy - Pharmacy claims for goods and services
  • professional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consulting
  • institutional - Hospital, clinic and other inpatient claims
coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

use
required, string

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Value: preauthorization
patient
required, object

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

Must be a resource of type Patient.

reference
string

A reference to a Patient resource

created
required, string

The date this resource was created.

provider
required, object

The provider which is responsible for the claim, predetermination or preauthorization.

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

priority
required, object

The provider-required urgency of processing the request. Typical values include: stat, routine, and deferred. If sending one of these statuses, use the system http://terminology.hl7.org/CodeSystem/processpriority

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

insurance
required, [object]

Financial instruments for reimbursement for the health care products and services specified on the claim.

sequence
required, number

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

focal
required, boolean

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Value: true
coverage
required, object

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Must be a resource of type Coverage.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

item
required, [object]

A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

sequence
required, number

A number to uniquely identify item entries.

productOrService
required, object

For prior auth, the requestedService extension carries more information than this field, and this field should just duplicate the product or service code found in that resource.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

extension
[itemTraceNumber, administrationReferenceNumber, requestedService, Other]

A set of additional fields about the item. For medication prior auth, the requestedService extension must be present with a reference to a MedicationRequest resource. For procedures, a ServiceRequest resource is used.

Any of:

Uniquely identifies this claim item. (2000F-TRN)

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
valueIdentifier
object

Uniquely identifies this claim item

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

informationSequence
[number]

Exceptions, special conditions and supporting information applicable for this service or product.

modifier
[object]

Item typification or modifiers codes to convey additional context for the product or service.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

quantity
object

The number of repetitions of a service or product.

value
number

The value of the measured amount. The value includes an implicit precision in the presentation of the value.

_value
object

This element contains extensions for value. Depending on the extensions present it could be used in place of value or contain additional information about value. See the extension element for more details on the possible extensions being sent.

extension
[Precision, Other]

A Precision extension allows the communication of values more precise than a JSON number, for example, 3.10 as opposed to just 3.1.

Any of:

Explicit precision of the number. If the actual value is 3.10, the value field will contain the number 3.1 while the precision extension will contain 2.

See http://hl7.org/fhir/StructureDefinition/quantity-precision for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/StructureDefinition/quantity-precision
valueInteger
required, number

Number of significant decimal places after the decimal.

unit
string

A human-readable form of the unit.

enterer
object

Individual who created the claim, predetermination or preauthorization.

Must be a resource of type PractitionerRole.

reference
string

A reference to PractitionerRole resource, which should point to both Practitioner and Organization.

insurer
object

The Insurer who is target of the request.

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

related
[object]

Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

claim
object

Reference to a related claim.

Must be a resource of type Claim.

reference
string

Contains the resource ID of the original claim that this resource is updating

relationship
object

When modifying a prior claim, set this to code='prior' and system='http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship'

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

careTeam
[OverallClaimMember, ItemClaimMember, Other]

The members of the team who provided the products and services.

Any of:
extension
required, [careTeamClaimScope, Other]

An Extension

Any of:

A flag that indicates whether the care team applies to the entire claim or a single item.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
sequence
required, number

A number to uniquely identify care team entries.

provider
required, object

Member of the team who provided the product or service.

Must reference one of the following types of resources:

  • Practitioner
  • Organization
reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

supportingInfo
[AdmissionDates, DischargeDates, AdditionalInformation, MessageText, Other]

An array of supporting information for the claim. Each piece of information is is linked to a claim line item via sequence and its type is identified by category

Any of:

Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

sequence
required, number

A number to uniquely identify supporting information entries.

category
required, object

The general class of the information supplied: information; exception; accident, employment; onset, etc.

coding
required, [object]

A reference to a code defined by a terminology system.

system
required, string

The identification of the code system that defines the meaning of the symbol in the code.

Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
code
required, string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Value: admissionDates
text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

timingDate
required, string

The date when or period to which this information refers.

Only one of timingDate, timingPeriod may be present.

timingPeriod
required, object

The date when or period to which this information refers.

Only one of timingDate, timingPeriod may be present.

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

start
string

A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

_start
object

Extensions for start

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

end
string

A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

_end
object

Extensions for end

id
string

A sequence of Unicode characters

extension
[object]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

id
string

A sequence of Unicode characters

url
string

String of characters used to identify a name or a resource

valueBase64Binary
string

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

diagnosis
[object]

Information about diagnoses relevant to the claim items.

sequence
required, number

A number to uniquely identify diagnosis entries.

diagnosisCodeableConcept
required, object

The nature of illness or problem in a coded form or as a reference to an external defined Condition.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

accident
object

Details of an accident which resulted in injuries which required the products and services listed in the claim.

date
required, string

Date of an accident event related to the products and services contained in the claim.

type
object

The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

post/Claim/$submit-preauthorization
Open dropdown

A request to authorize payment for a blood pressure medication

Response Fields and Example
resourceType
required, string

Identifies the type of the resource

Value: Bundle
type
required, string

Indicates the purpose of this bundle - how it is intended to be used.

Value: collection
timestamp
required, string

The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

entry
required, [ClaimResponse, Patient, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, Claim, Other]

An array of FHIR resources including the following:

  • ClaimResponse - the primary response resource
  • Patient - the patient the claim response is about
  • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
  • Coverage - the patient's insurance

The ClaimResponse is the only resource that must be present in the bundle. It references several other of the above resources which should already be known to the requesting system.

However, some workflows may not always persist the information, so it is best practice for the responding system to preserve and re-include all referenced resources in the Claim Response bundle.

Any of:

An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

resource
required, object

This resource provides the adjudication details from the processing of a Claim resource.

resourceType
required, string

Identifies the type of the resource

Value: ClaimResponse
status
required, string

The status of the resource instance.

Value: active
type
required, object

Type of claim. Example Codes

For prescriptions, typically code='pharmacy' and system='http://terminology.hl7.org/CodeSystem/claim-type'

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

use
required, string

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Value: preauthorization
patient
required, object

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Must be a resource of type Patient.

reference
string

A reference to a Patient resource

created
required, string

The date this resource was created.

insurer
required, object

The party responsible for authorization, adjudication and reimbursement.

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

outcome
required, string

The outcome of the claim, predetermination, or preauthoirization processing.

queued | complete | error | partial

Possible Values: queued, complete, error, partial
requestor
object

The provider which is responsible for the claim, predetermination or preauthorization.

Must be a resource of type Organization.

reference
string

A reference to an Organization resource

request
object

A reference to the Claim resource triggering adjudication. This can be either the same identifier as the original Claim.identifier or else reference can point to the Claim.id value. When sending only the reference, it is helpful to also include the original Claim resource in the request.

Must be a resource of type Claim.

reference
string

A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

identifier
object

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

extension
[Boolean, String, CodeableConcept, Coding, HumanName, Reference]

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

One of:
url
required, string

Source of the definition for the extension code - a logical name or a URL.

valueBoolean
boolean

A single value for the extension.

use
string

The purpose of this identifier.

Possible Values: usual, official, temp, secondary, old (If known)
system
string

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

item
[object]

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

itemSequence
required, number

A number to uniquely reference the claim item entries.

adjudication
required, [object]

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

category
required, object

Type of adjudication information. Example Codes

coding
required, [object]

A reference to a code defined by a terminology system.

system
required, string

The identification of the code system that defines the meaning of the symbol in the code.

Value: http://terminology.hl7.org/CodeSystem/adjudication
code
required, string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Value: submitted
text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

extension
[reviewAction, Other]

An Extension

Any of:

The details of the review action that is necessary for the authorization.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
extension
[code, number, Other]

Details of the review action that is necessary for the authorization, carried in sub-extension properties.

Any of:

The code describing the result of the review.

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
valueCodeableConcept
object

Code indicating the type of action, from the X12 306 code set.

coding
[object]

A reference to a code defined by a terminology system.

system
string

The identification of the code system that defines the meaning of the symbol in the code.

code
string

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

text
string

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

amount
object

Monetary amount associated with the category.

value
number

Numerical value (with implicit precision).

currency
string

ISO 4217 Currency Code (e.g. USD for US Dollar)

value
number

Non-monetary value. Used, for example, when the adjudication is a percentage.

extension
[itemTraceNumber, preAuthIssueDate, preAuthPeriod, administrationReferenceNumber, authorizedItemDetail, communicatedDiagnosis, Other]

Additional information about the item

Any of:

Uniquely identifies this claim item. (2000F-TRN)

See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

url
required, string

Source of the definition for the extension code - a logical name or a URL.

Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
valueIdentifier
object

Uniquely identifies this claim item

value
string

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

processNote
[object]

A note that describes or explains adjudication results in a human readable form.

text
required, string

The explanation or description associated with the processing.

Open dropdown

A claim response demonstrating inclusion of the original resources associated with the claim request. Many of these resources are redundant and need not actually be sent with a response bundle.