docs(data-integration): add the prior authorization feed - #94
Open
Nesmeshnoy wants to merge 3 commits into
Open
Conversation
The filenames carry a content hash so that an edited template reaches readers at a new URL. These were edited without re-running the hashing script, so the names no longer matched the content. Co-Authored-By: Claude Opus 5 <noreply@anthropic.com>
US Core requires a Practitioner to carry an identifier and a family name, not specifically an NPI, and the organizations dataset already accepts another stable id with its issuing system. Practitioners was the outlier, so a clinician known only by an internal id had no way into the feed. Co-Authored-By: Claude Opus 5 <noreply@anthropic.com>
Three datasets built to Da Vinci PDex STU 2.1.0: prior_auths for the authorization and its decision, prior_auth_lines for the items it covers, prior_auth_documents for the link to the documentation a provider submitted. An authorization becomes one ExplanationOfBenefit with use = preauthorization. Columns, requiredness and value sets follow the pdex-priorauthorization profile and the PAS item extensions it reuses. Example code values are the ones the published PDex and PAS examples carry, so no licensed X12 code list is reproduced. Two points where the obvious reading of the profile is wrong: - A line is identified by a procedure code or by a revenue code. PDex binds item.productOrService to CPT, HCPCS and HIPPS, so a facility authorization carrying only a NUBC revenue code cannot use it. revenue_code is first-class and service_code is conditional on it. - outcome is a processing state, not a decision. FHIR defines queued as received but not yet begun and complete as finished without errors, and the base spec splits the adjudication result into its own element in R6. The decision lives in the review action and the denial columns, and a cancelled authorization keeps the outcome it had reached while status carries the cancellation. Amounts are included. Patient Access serves a member their own authorization amounts, PDex marks the adjudication amount slice and total.category must-support, and the IG example carries both. Lines take the claims feed's amount columns, fourteen of the sixteen: PDex has no paidbypatientcash or paidbypatientother. Co-Authored-By: Claude Opus 5 <noreply@anthropic.com>
Nesmeshnoy
force-pushed
the
pdex-prior-auth-feed
branch
from
September 11, 2026 19:10
33a2837 to
70ad114
Compare
This file contains hidden or bidirectional Unicode text that may be interpreted or compiled differently than what appears below. To review, open the file in an editor that reveals hidden Unicode characters.
Learn more about bidirectional Unicode characters
Sign up for free
to join this conversation on GitHub.
Already have an account?
Sign in to comment
Add this suggestion to a batch that can be applied as a single commit.This suggestion is invalid because no changes were made to the code.Suggestions cannot be applied while the pull request is closed.Suggestions cannot be applied while viewing a subset of changes.Only one suggestion per line can be applied in a batch.Add this suggestion to a batch that can be applied as a single commit.Applying suggestions on deleted lines is not supported.You must change the existing code in this line in order to create a valid suggestion.Outdated suggestions cannot be applied.This suggestion has been applied or marked resolved.Suggestions cannot be applied from pending reviews.Suggestions cannot be applied on multi-line comments.Suggestions cannot be applied while the pull request is queued to merge.Suggestion cannot be applied right now. Please check back later.
Adds the prior authorization feed to the Data Integration Reference.
prior_authsExplanationOfBenefitwithuse = preauthorizationprior_auth_linesExplanationOfBenefit.itemof the same profileprior_auth_documentssupportingInfolink to the US Core DocumentReference built fromdocumentsColumns, requiredness and value sets follow Da Vinci PDex STU 2.1.0 and the PAS item extensions it reuses. Example code values are the ones the published PDex and PAS examples carry, so no licensed X12 code list is reproduced.
Two points worth a careful read:
A line is identified by
service_codeor byrevenue_code. PDex bindsitem.productOrServiceto CPT, HCPCS and HIPPS, so a facility authorization carrying only a NUBC revenue code cannot use that element.revenue_codeis first-class andservice_codeis conditional on it.outcomeis a processing state, not the decision. R4 definesqueuedas received but not yet begun andcompleteas finished without errors, and the base spec splits the adjudication result into its own element in R6. The decision lives in the review action and the denial columns, so a cancelled authorization keeps the outcome it had reached and reports the cancellation instatus.Amounts are included: Patient Access serves a member their own authorization amounts, PDex marks the adjudication amount slice and
total.categorymust-support, and the IG example carries both. Lines take the claims feed's amount columns, fourteen of the sixteen, since PDex has nopaidbypatientcashorpaidbypatientother.Two changes ride along:
practitionersaccepts a non-NPI identifier with its issuing system, the wayorganizationsalready does. US Core requires a Practitioner to carry an identifier and a family name, not specifically an NPI. @akim1995 this one is yours: two rows and a template column.