PdexPriorAuthorization

PDex Prior Authorization

activeDa Vinci PDex2.1.0resource40 key elements

The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members.

Metadata

hl7.org/fhir
Canonical URL
http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
ID
pdex-priorauthorization
Type
Base Definition
Derivation
constraint
Mandatory and Must-Support Elements

Elements with cardinality > 0 or marked as Must Support (S)

PathCard.TypeFlagsDescription
meta.profile
1+
:supportedProfile1..1
1+
:levelOfServiceType0..1
Extension
S
A code specifying the level of service being requested (UM06)
status
S
type
S
use
S
patient
Reference
S
enterer
Reference
S
insurer
Reference
S
provider
Reference
S
facility
Reference
S
preAuthRefPeriod
S
careTeam.provider
Reference
S
:itemTraceNumber0..*
Extension
S
Uniquely identifies this claim item. (2000F-TRN)
:preAuthIssueDate0..1
Extension
S
The date when this item's preauthorization was issued.
:preAuthPeriod0..1
Extension
S
The date/period when this item's preauthorization is valid.
:previousAuthorizationNumber0..1
Extension
S
A string assigned by the UMO to an authorized review outcome associated with this service item.
:administrationReferenceNumber0..1
Extension
S
A string assigned by the UMO to the original disallowed review outcome associated with this service item.
:authorizedItemDetail0..1
Extension
S
The details of what has been authorized for this item if different from what was requested.
:authorizedProvider0..*
Extension
S
The specific provider who has been authorized to provide this item.
item.category
S
:reviewAction0..1
Extension
S
The details of the review action that is necessary for the authorization at the line level.
:adjudicationActionDate0..1
Extension
S
The date/time when an Adjudication Action occured.
:adjudicationamounttype0..*
S
item.adjudication.amount
S1+
:allowedunits0..1
S
item.adjudication.value
S1+
:denialreason0..*
S
item.adjudication.reason
S1+
item.adjudication.value
1+
adjudication
BackboneElement
S
:reviewAction0..1
Extension
S
The details of the review action that is necessary for the authorization for the entire request.
:adjudicationActionDate0..1
Extension
S
The date/time when an Adjudication Action occured.
adjudication.category
S
:adjudicationamounttype0..*
S
adjudication.amount
1+
:denialreason0..*
S
adjudication.reason
S1+
:priorauth-utilization0..1
Extension
S
total.category
S
Prior Authorization utilization codes