ESMD FHIR Implementation Guide
1.0.0 - esmd
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
Prior Authorization Decision Letters (PADL) A PADL is a formal communication sent by a CMS Review Contractor (RC) to inform healthcare providers and patients about the outcome of a prior authorization request. Prior Authorization (PA) is a process where a healthcare provider must obtain approval from the insurance company before providing certain treatments, medications, or services to a patient. This is done to ensure the requested treatment or service is covered by the patient's insurance plan and is deemed medically necessary.
Review Result Letter (RRL) A RRL is a formal communication sent by a CMS Review Contractor (RC) that informs the recipient of the outcome of a request review process. It indicates that the request was affirmed (approved), non-affirmed (denied), or partially affirmed (partially approved). A RRL provides the necessary details and rationale for the decision. If applicable, the RRL also outlines the next steps, including how to appeal a decision. RRLs play a crucial role in maintaining transparency, clarity, and effective communication between CMS, healthcare providers, and patients.
The following metadata elements are used to facilitate the retrieval of document submission metadata and content for PADLs and RRLs which are stored in the esMD System's secure storage. PADLs and RRLs are retrieved by HIHs and Providers from the esMD System's secure storage using the Esmd-FindDocumentReference and esMD Binary resources.
| esMD Element Name | FHIR Element Name | Cardinality | Element Description |
| letterid | Esmd-Idn-LetterId | 1..1 | A unique identifier that is assigned to each individual PADL or RRL that is sent by the RC. It ensures that each PADL or RRL can be uniquely identified and tracked throughout the submission and review process. The Letter ID plays a crucial role in preventing duplication, ensuring proper routing, and facilitating accurate processing and auditing of clinical documents that are handled by the esMD system and RCs. |
| esmdtransactionid | Esmd-Ext-TransactionId | 1..1 | A unique identifier which is assigned by the esMD System to each PADL or RRL that is received from RCs. The Transaction ID provides clear and efficient tracking for auditing, status reporting, and seamless management of submissions and responses within the esMD workflow. |
| senderoid | Esmd-Ext-OrganizationId | 1..1 | An Organizational Identifier (OID) that uniquely identifies the RC organization that submits a PADL or RRL to a receiving HIH/Provider organization using the esMD System. |
| receiveroid | Esmd-Ext-ReceiverOid | 1..1 | An Organizational Identifier (OID) that uniquely identifies the receiving HIH/Provider organization that is the recipient of a PADL or RRL when the submitting RC organization uses the esMD System. |
| providernpi | Esmd-Ext-NPI | 0..1 | A unique identification number assigned to healthcare providers who transmit PADL or RRL documents electronically using the esMD System. The National Provider Identifier (NPI) is used within the esMD System to ensure that PADLs or RRLs are accurately linked to the correct healthcare provider. |
| eMDRType | Esmd-Ext-RequestType | 1..1 | Used during the document retrieval request process to identify the document as a PADL or RRL document when HIHs or Providers submit a document retrieval request to the esMD System. |
| contenttypecode | Esmd-Ext-LineOfBusinessId | 1..1 | Used to identify the specific Line of Business (LOB) that is associated with the PADL or RRL document that is retrieved from the esMD System by HIHs or Providers. The LOB ID helps to classify and route submissions based on the type of service or payer-related information, thereby ensuring that PADL or RRL documents are processed according to the correct business category. |
| creationtime | date ( type- Instant) | 1..1 | Represents the date and time the PADL or RRL was created by the esMD System to indicate that the document was ready to download. |
The following metadata elements are used to facilitate the retrieval of document metadata and content for PADLs and RRLs which are stored in the esMD System’s secure storage. PADLs and RRLs are retrieved by HIHs and Providers from the esMD System’s secure storage using the Esmd-FindDocumentReference and esMD Binary resources.
| esMD Element Name | FHIR Element Name | Cardinality | Element Description |
| attachment.id | content.attachment.id | 1..1 | Represents name of the PADL or RRL document content which is assigned by the esMD System when the content was uploaded to esMD secure storage. The Attachment ID is used during the document retrieval process. |
| language code | content.attachment.language | 1..1 | Specifies the human language or character data in the PADL or RRL. The Language Code must always be ‘en-US’. |
| size | content.attachment.size | 1..1 | Specifies the file size of the PADL or RRL. |
| classcode | category | 1..1 | A code that specifies the particular kind of document. |
| confidentialitycode | securityLabel | 1..1 | A code that specifies the level of confidentiality that is assigned to the PADL or RRL. For the esMD System, this code is always ‘V’: |
| formatcode | content.format | 1..1 | A globally unique code which specifies the format of the PADL or RRL document. |
| healthcarefacilitytypecode | context.facilityType | 1..1 | Represents the type of organizational or provider setting in which the acts documented in the PADL or RRL occurred. |
| mimetype | content.attachment.contentType | 1..1 | Used to identify the Multipurpose Internet Mail Extensions (MIME) format of the PADL or RRL content. |
| hash | content.attachment.hash | 1..1 | Represents the hash of the PADL or RRL based on the SHA 256 Hash Algorithm. |
| creationtime | content.attachment.creation | 1..1 | Represents the date that the PADL or RRL was uploaded to the esMD System’s secure storage. |
| title | content.attachment.title | 1..1 | The title which was assigned to the PADL or RRL. |
| url | content.attachment.url | 1..1 | Represents the Binary URL which is used by the HIH or Provider to retrieve the PADL or RRL from the esMD System’s secure storage. |