ESMD FHIR Implementation Guide - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

PA Response Metadata

Prior Authorization Response:

This notification message includes PA/PCR review responses in the event the RC has determined their decision for a PA/PCR request. This notification message could include one of the four responses: Affirmed (A), Non-Affirmed (N), Modified (M) – applicable only for Repetitive Scheduled Non-Emergent Ambulance Transport, Partially Affirmed (P) for the below Line Of Business within the esMD system

Prior Authorization/Pre-Certification Requests (PA/PCR) Submissions (CTC 8.1, 8.3,8.4, 8.5 and 8.6) PA/PCR submissions, which include specific programs such as Ambulance, HHPCR (Home Health Prior Authorization Requests), DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies), HOPD (Hospital Outpatient Department), and IRF (Inpatient Rehabilitation Facility), are used to submit documentation for prior authorization or pre-certification of services and procedures before they are performed.

esMD Metadata for Prior Authorization Response

ID	Data Element	Element Description	Validation Rule	Length and Format	Usage
1	TransactionId	esMD TransactionID is generated by the esMD when a PA request is received from the HIH	1. Valid transaction ID	15 Alphanumeric	R
2	SenderOID	The Intended Recipient refers to the organization (RC) that will receive the message from the sender (HIH) containing the esMD Claim supporting documents. This Intended Recipient will be uniquely identified using an OID (Object Identifier) issued by HL7.	1. Valid Sender OID	1. Length must be between 1 to 64 Characters 2. Format must be as stated: ""urn:oid:1.3.6.1.4.1.101420.6.1""	R
3	ReceiverOID	A Globally Unique Identifier (GUID), in OID (Object Identifier) format, is used to uniquely identify the Health Information Handler (HIH). This identifier ensures that the HIH can be distinctly recognized across systems, providing a consistent and reliable reference within the health information management process.	1. Valid Receiver OID	1. Length must be between 1 to 64 Characters 2. Format must be as stated: "urn:oid:1.3.6.1.4.1.101420.6.1"	R
4	ContentTypeCode	The Content Type Code identifies the specific line of business for which the provider or Health Information Handler (HIH) is submitting the request.	1. Content Type Code or Line of Business ID must be part of esMD and in active status	1. Length 1 -16 2. Format must be numeric with period Ex: ""1 or 1.1or 11""	R
5	CreationTime	The creation date and time stamp is an element that represents the date and time when the Health Information Handler (HIH) created the document that is being processed by esMD.	1.     Valid Time format	Time format used is YYYY-MM-DDThh:mm:ss+zz:zz	S
6	RequestLevelDecisionResponse	The value of this data element shall represent based on the decisions in the service lines. Affirmed (A), Non-affirmed (N), Partially Affirmed (P), Modified (M) are the applicable values.	NA	The value of this data element shall indicate whether THE response has been Affirmed (A) or Non affirmed (N) or Modified (M) Partially Affirmed (P).	S
7	UniqueTrackingNumber	A unique tracking number assigned by the RCs. The provider/RC supplier uses this number to file a claim with CMS.	1.     Unique value of the UTN	2.     Alphanumeric and length 14 characters.	S
8	ServiceLineItemNumber	ServiceLineNumber uniquely identifies each service in the received response.	Max of 40 services	1.     Numeric value	S
9	DecisionIndicator	The value of this data element shall indicate whether the response has been Affirmed (A) or Non-affirmed (N) or Modified (M)	1.     Either A, M, or N		S
10	ProcedureCode	Procedure Code Situational for XDR which uniquely identify the program type.	1.     Valid procedure code active in esMD	Alphanumeric with 5 characters	S
11	ProgramReasonCode	These values will be available in the non-affirmed decision response. Accept Alphanumeric and length 5 char.	NA	Alphanumeric with 5 characters	S
12	ApprovedDate	The date for which the decision indicator M was approved for.	1. Current or future Date	1. Format check of YYYY-MM-DD	S
13	ApprovedUnits	The units that were approved for decision indicator M	1.     Units greater than 0 less than 999	Numeric 1- 999	S
14	ProposedDateOfService	The Proposed Date of Service indicates the Billing Period date for that procedure code.	1.     Date not exceeding 30 days	Format check YYYY-MM-DD – YYYY-MM-DD	S

Prior Authorization Reject Response:

This notification message includes PA/PCR reject response in the event the RC has determined their decision to reject the PA/PCR request. Below is the list of metadata elements for the following Lines of Business (LOBs):

Prior Authorization/Pre-Certification Requests (PA/PCR) Submissions (CTC 8.1, 8.3,8.4, 8.5 and 8.6) PA/PCR submissions, which include specific programs such as Ambulance, HHPCR (Home Health Prior Authorization Requests), DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies), HOPD (Hospital Outpatient Department), and IRF (Inpatient Rehabilitation Facility), are used to submit documentation for prior authorization or pre-certification of services and procedures before they are performed.

esMD Submission Metadata for Prior Authorization Reject Response

ID	Data Element	Element Description	Validation Rule	Length and Format	Usage
1	esMDTransactionId	esMD TransactionID is generated by the esMD when a PA request is received from the HIH	Valid transaction ID	15 Alphanumeric	R
2	hihOID	A Globally Unique Identifier (GUID), in OID (Object Identifier) format, is used to uniquely identify the Health Information Handler (HIH). This identifier ensures that the HIH can be distinctly recognized across systems, providing a consistent and reliable reference within the health information management process.	1. Valid Receiver OID	1. Length must be between 1 to 64 Characters 2. Format must be as stated: ""urn:oid:1.3.6.1.4.1.101420.6.1""	R
3	senderOID	The Intended Recipient refers to the organization (RC) that will receive the message from the sender (HIH) containing the esMD Claim supporting documents. This Intended Recipient will be uniquely identified using an OID (Object Identifier) issued by HL7.	1. Valid Sender OID	1. Length must be between 1 to 64 Characters 2. Format must be as stated: ""urn:oid:1.3.6.1.4.1.101420.6.1""	R
4	totalNumberOfDocuments	totalNumberofDocuments indicates the total number of attachments	Numeric value		R
5	creationTime	The creation date and time stamp is an element that represents the date and time when the Health Information Handler (HIH) created the document that is being processed by esMD.	Valid Time format	Time format used is YYYY-MM-DDThh:mm:ss+zz:zz	R
6	contentTypeCode	The Content Type Code identifies the specific line of business for which the provider or Health Information Handler (HIH) is submitting the request.	1. Content Type Code or Line of Business ID must be part of esMD and in active status	1. Length 1 -16 2. Format must be numeric with period Ex: ""1 or 1.1or 11""	R
7	requestType	Indicates the request Type as ‘PARejectResponse’			R