Prior Authorization Support System API - Implementation Template

Prior Authorization Developer Guide

Prior Authorization provides helper functions for mapping FHIR objects to X12 ones and reverse.

fhirtoAdditionalInfo275

Module that provides support for submit 275 request mapping.

Source: .src/main/resources/dwl/Submit/fhirtoAdditionalInfo275.dwl

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fhirToSubmitRequest278

Module that provides support for submit 278 request mapping.

Source: .src/main/resources/dwl/Submit/fhirToSubmitRequest278.dwl

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submitResponse278toFHIR

Module that provides support for submit 278 response mapping.

Source: .src/main/resources/dwl/Submit/submitResponse278toFHIR.dwl

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claimInquiryResponse278toFHIR

Module that provides support for inquiry 278 response mapping.

Source: .src/main/resources/dwl/Inquiry/claimInquiryResponse278toFHIR.dwl

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fhirTo278Inquiry

Module that provides support for inquiry 278 request mapping.

Source: .src/main/resources/dwl/Inquiry/fhirTo278Inquiry.dwl

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x12SegmentTools

This module implements X12 segment tools needed for
270 and 271 segments.

Source: .src/main/resources/dwl/x12Util/x12SegmentTools.dwl

Functions

fun getResource (resourceBundle, resourceId, resourceType)

Function to get resource from bundle using either resourceId or resourceType.

param resourceBundle is the payload bundle to be filtered.
param resourceId is the ID of the resource to be used for filtering resources.
param resourceType is the type of resource to be used for filtering resources. Use either resourceId or resourceType for filtering.

fun createN3 (n3Type, n301, n302)

Creates a N3 address object with the provided arguments.

param n3Type is a string with the N3 type.
param n301 is the first address line.
param n302 is the second address line.
return A formatted N3 address object.

fun createN4 (n4Type, n401, n402, n403, n404, n407)

Creates an N4 address (city, state, zip) object with the provided arguments. Limitation - Doesn't support N407. Assuming address is within United States of America, including its territories, or Canada

param n4Type is a string with the N$ type.
param n401 is a string with the address city.
param n402 is a string with the address state.
param n403 is a string with the address postal code.
param n404 is a string with the address country.
param n407 is a string with the address district.
return A formatted N4 address object.

fun createDTP (dtpType, dtp01, dtp02, dtp03)

Creates a DTP (date time period) object with the provided arguments.

param dtpType is a string with DTP type.
param dtp01 is a string with DTP qualifier.
param dtp02 is a string with DTP format qualifier.
param dtp03 is a string with DTP value.
return A formatted DTP object.

fun createREF (refType, ref01, ref02)

Creates a REF segment with provided arguments.

param refType is a string with the provider code.
param ref01 is a string with the reference identification qualifier.
param ref02 is a reference with the ref02 element name being constructed with refType and REF02.
return X12 formatted REF segment.

fun getFHIRResource (inRequest, resourceId)

Function to look up a resource from the bundle based on resource's ID. Example: Pass in an Organization's ID and the response would be the Organization object from the bundle.

param inRequest - Input request to the API.
param resourceId - ID of resource to be looked up.
return Resource Object for the matching resource.

fun createPER (perType, per01, per02, per03, per04, per05, per06, per07, per08)

Creates a PER contact information object with the provided arguments.

param perType is a string with the PER type.
param per01 is a string with the function code.
param per02 is a string with the Contact name.
param per03 is a string with the number qualifier.
param per04 is a string with the number value.
param per05 is a string with the second number qualifier.
param per06 is a string with the second number value.
param per07 is a string with the third number qualifier.
param per08 is a string with the third number value.
return A formatted PER contact information object.

fun createSV303 (inputData)

Creates a SV303 oral cavity designation object with the provided arguments.

param inputData is a claim resource object.
return A SV303 oral cavity object.

fun createSV3 (inputData)

Creates a SV3 dental service object with the provided arguments.

param inputData is a claim resource object.
return A formatted SV3 dental service object.

fun createSV1 (sv101_01, sv101_02, sv101_03, sv101_04, sv101_05, sv101_06, sv101_07, sv101_08, sv102, sv103, sv104)

Creates a SV1 professional service object with the provided arguments.

param sv1_1 is a string with the EPSDT indicator.
param sv1_2 is a string with product or service ID qualifier.
param sv1_3 is a claim resource object.
return A formatted SV1 professional service object.

fun createSBR (perType, per01, per02, per03, per04, per05, per09)

Creates a SBR contact information object with the provided arguments.

param perType is a string with the PER type.
param per01 is a string with the Contact Function Code.
param per02 is a string with the Contact name.
param per03 is a string with the Communication Number Qualifier.
param per04 is a string with the Communication Number.
param per05 is a string with the Communication Number Qualifier.
param per09 is a string with the Contact Inquiry Reference.
return A formatted PER contact information object.

fun genderLookup (gndr)

Formats the provided gender string into a valid gender string that can be cast to the gender value.

param gndr is the string with gender type.
return A required gender value.

fun createDMG (dmgType, dmg01, dmg02, dmg03)

Creates a DMG demographic information object with the provided arguments.

param dmgType is a string with the DMG type.
param dmg01 is a string with the format qualifier.
param dmg02 is a patient object.
return A formatted DMG demographic information object.

fun payerSequenceNumberPayerLookup (code)

Formats the provided gender string into a valid gender string that can be cast to the gender value.

param gndr is the string with gender type.
return A required gender value.

fun relationCodeX12FHIR (inCode)

Function to convert X12 relationship code to FHIR format.

param inCode X12 relationship code.
return FHIR format relationship code.

fun genderLookupX12FHIR (inCode)

Function to convert X12 Gender Codes to FHIR format.

param inCode X12 Gender code.
return FHIR format Gender code.

fun telecomTypeX12FHIR (inCode)

Function to convert X12 telecom codes to FHIR format.

param inCode X12 relationship code.
return FHIR format relationship code.

fun createTelecom (perSegment)

Function create telecom object for FHIR resource using X12 PER segment.

param perSegment PER segment from X12 message.
return telecom object formatted per FHIR specification.

fun pluckValuefromSeg (segment, selector)

Function to fetch an element from the segment with the key name prefix.

param segment from which the element value is to be extracted.

fun createPWK (pwkType, pwk01, pwk02, pwk05, pwk06)

Function that creates a PWK segment using the provided parameters.

param pwkType Describes the PWK segment being mapped.
param pwk01 Report Type code.
param pwk02 Report Transmission code.
param pwk05 Attachment control number.
param pwk06 Attachment description.
return X12 formatted BIN segment.

fun createMSG (msgType, msg01)

Function create MSG segment using the provided parameters.

param msgType Describes the MSG segment being mapped.
param msg01 Message to be written to MSG segment.
return X12 formatted MSG segment.

fun benefitTypeLookup (x12BenefitType)

Function to translate X12 benefit type to FHIR format.

param x12BenefitType - X12 benefit type.
return FHIR benefit format benefit type.

fun createPRV (prvType, prv01, prv02, prv03)

Creates a PRV provider information object with the provided arguments.

param prvType describes the provider type being mapped. Not currently in use now, but it could be used if multiple PRV segments with varying fields names are required.
param prv01 is a string with the provider code.
param prv02 is a string with the reference identification qualifier.
param prv03 is a string with the provider taxonomy code.
return X12 formatted PRV segment.

fun termTypeLookup (x12TermCode)

Function to convert term type from X12 to FHIR.

param x12TermCode - X12 term type.
return FHIR format term type.

fun createResponseItem (item, fhirConstants)

Function to create an item array within CoverageEligibilityResponse.

param item - item is the input x12's EB segment.
param itemCategorySystem - system identifier for item's category.
return - An array of item with benefit and other details.

fun fetchBenefitLoop (dependentPatientExists, benefitsLoop)

Function to fetch the benefits loop based on the patient being a subscriber or a dependent.

param dependentPatientExists - Boolean indicating if the patient is the subscriber or dependent.
param benefitsLoop - X12 271's 2100C or 2100D based on the patient being a dependent or subscriber.

fun createCoverageEligibilityResponse (fhirConstants, covRespId, bhtSegment, patientId, requesterType, requestorId, outcome, payorId, coverageId, benefitPeriod, benefitsLoop, dependentPatientExists)

Function to create CoverageEligibilityResponse.

param fhirConstants - List of constants used to for identifiers and system.
param covRespId - Unique ID for CoverageEligibilityResponse.
param bhtSegment - BHT segment from X12 271 input.
param patientId - the patient's ID (either subscriber or dependent) from X12 271 2100C Loop.
param requesterType - Type of the party sending the CoverageEligibilityRequest can be either Practitioner or Organization.
param requestorId - ID of the sender of the CoverageEligibilityRequest.
param outcome - Outcome of the 271 X12 based on AAA segment.
param payorId - ID of the Information Source i.e. the payer in this case.
param coverageId - ID of the Coverage created as part of the bundle.
param benefitPeriod - Benefit begin and end date.
param benefitsLoop - 2110D or 2110C loop of the X12 271 based on the patient.
param dependentPatientExists - Boolean indicating if patient is the subscriber or dependent.

fun RelationshipLookup (relateship)

Formats the provided coverage relationship string into a valid relationship string that can be cast to the relationship value. Limitation: Only supports FHIR relations: Spouse, Child and Other Relationship.

param relateship is the string with gender type.
return A required gender value.

fun createINS (insType, ins01, ins02)

Function to create INS segment with provided input parameters.

param insType - INS segment for patient(subscriber or dependent).
param ins01 - insured indicator.
param ins02 - relationship to insured.
return An X12 formatted INS segment.

fun createINS (insType, ins01, ins02, ins08)

Creates an INS object with the provided arguments.

param ins01 is an Insured Indicator value.
param inso2 is value for Individual Relationship Code.
param ins08 is a string with Employment Status Code.
return X12 formatted INS segment.

fun insuredRelationLookup (relCode)

Formats the provided relationship code into a valid code that can be cast to relationship code.

param relCode is the code with relationship type.
return A required relationship code.

fun createBIN (bin01)

Creates a BIN object with the provided arguments.

param bin01 is a Binary Data value.
return X12 formatted BIN segment.

fun createEFI (efi01)

Creates a EFI (Electronic Format Identification) object with the provided arguments.

param efi01 is a Security Level Code.
return X12 formatted EFI segment.

fun createCAT (cat01, cat02)

Creates a CAT (Category Of Patient Information Service) object with the provided arguments.

param cat01 is a Attachment Report Type Code.
param cat02 is a Attachment Information Format Code.
return X12 formatted CAT segment.

fun createLX (lx01)

Creates a LX object with the provided arguments.

param lx01 is a Assigned Number.
return X12 formatted LX segment.

fun createNX1 (nx1_01)

Creates a NX1 object with the provided arguments.

param nx1_01 is a Entity Identifier Code.
return X12 formatted NX1 segment.

fun providerTypeLookup (inCode)

Function to convert provider type from FHIR to X12 format.

param inCode FHIR format lookup value.
return X12 format qualifier for provider.

fun lookupPERCommType (inCode)

Function to convert PER segments from FHIR format to X12 format.

param inCode - Telecom system in FHIR.
return X12 format communication type qualifier.

fun extensionLookUp (extension, valueType, url)

Function to lookup extension using URL comparison and return the appropriate code based on type of extension.

param extension - Array of extensions to be filtered.
param valueType - Defines whether extension is of valueCodeableConcept or string.
param url - URL of the extension being filtered identifying MilitaryStatus, leveOfService etc.

fun fetchSupportingInfo (supportingInfoArray, eventCode, eventSystem)

Function to fetch claim resource's supporting Info for Patient Event, Admission, Discharge, AdditionalInfo, Message etc.

param supportingInfoArray - List of supportinginfos from FHIR PAS Claim Resource.
param eventCode - Codeable concept's code to filter the list.
param eventSystem - Codeable concept's system to filter the list.
return - supportingInfo from FHIR Claim that matches the code and system.

fun formatPeriod (periodObject)

X12 formats the period range string with the provided FHIR period object.

param periodObject is an FHIR-formatted period object.
return An X12 period range string.

fun formatDateTime (str)

Formats the provided date string into a valid datetime string that can be cast to a date or a time.

param str is the current datetime string.
return A datetime formatted string.

fun createTRN (trnType, trn01, trn02, trn03, trn04)

Creates a TRN object with the provided arguments.

param trnType is a string with TRN type.
param trn01 is value for Trace Type code.
param trn02 is a string with TRN type Trace Number.
param trn03 is a string with Trace Assigning Entity Identifier.
param trn04 is a string with Trace Assigning Entity Additional Identifier.
return X12 formatted TRN segment

fun createHI (hi101, hi102, hi201, hi202)

Function to create HI segment with provided input parameters.

param hi101 - Diagnosis code classification library identifier.
param hi102 - Diagnosis code.
param hi201 - Diagnosis code classification library identifier.
param hi202 - Diagnosis code.
return An X12 formatted HI segment.

fun createHI (hi01, hi02)

Creates a HI healthcare information object with the provided arguments.

param hi01 is a segment qualifier for diagnosys code admitting.
param hi02 is a segment qualifier for diagnosys code principal.
param hi03 is a segment qualifier for diagnosys code patientreasonforvisit.
param hi04 is a string with diagnosys code.

fun createUM (um01, um02, um03, um0401, um0402, um0501, um0504, um06)

Creates an UM object with the provided arguments.

param um01 is request category code.
param um02 is certification type code.
param um03 is service type code.
param um0401 is a sub element of UM04 for facility code.
param um0402 is a sub element of UM04 for facility code qualifier.
param um0501 is a sub element of UM05 for related causes code.
param um0504 is a sub element of UM05 for state or province code.
param um0506 is the level of service code.
return X12 formatted UM segment.

fun createSubmit2000ELoop (inRequest, claimResource, segmentQualifiers, fhirConstantsObj, patientDates, claimSupportingInfo)

Function creates 2000E_Loop and its child loops like 2010EA and 2000F. 2000E_Loop includes TRN, UM, DTP,HI,PWK,MSG, 2010EA_Loop and 2000F_Loop. 2010EA_Loop includes NM1, N3, N4, PER, PRV. 2000F_Loop includes TRN, REF, UM, DTP, SV1 or SV2. This loop can occur in either 2000C at the subscriber level, when the subscriber is the patient, or it can occur at 2000D at the beneficiary level, when a dependent of the subscriber is the patient.

fun getEventLoop (loop2000E, loop2000FExists)

Function to get EventLoop from 2000E or 2000F. There are situations where, 2000F loops are not populated in the X12 message. This function looks at both and returns the one that is present

param loop2000E is the 2000ELoop from X12 278 Response
_param loop2000FExists is a boolean that identifies presence of 2000FLoop
_return Loop structure of either 2000E or 2000F

fun getExtensionValue (LoopESegName, LoopFSegName, LoopE_Element, LoopF_Element, loop2000FExists, loop2000E)

Function to get extension values segment in either 2000E or 2000F loops. There are situations where, 2000F loops are not populated in the X12 message. with parameters LoopESegName,LoopFSegName,LoopE_Element,LoopF_Element,loop2000FExists,loop2000E This function looks at both and returns the element from 2000F_Loop if it exists else from 2000E_Loop

param LoopESegName is the segment name from 2000ELoop of X12 278 Response
_param LoopFSegName is the segment name from 2000ELoop of X12 278 Response
_param LoopE_Element is the element name from 2000ELoop of X12 278 Response
_param LoopF_Element is the element name from 2000ELoop of X12 278 Response
_param loop2000FExists is a boolean that identifies presence of 2000FLoop
_param loop2000E is the 2000ELoop from X12 278 Response
_return Loop structure of either 2000E or 2000F

fun createInquiry2000ELoop (inRequest, claimResource, segmentQualifiers, fhirConstantsObj, patientDates, claimSupportingInfo)

Function creates 2000E_Loop and its child loops like 2010EA and 2000F. 2000E_Loop includes TRN, DTP, 2010EA_Loop and 2000F_Loop. 2010EA_Loop includes NM1, N3, N4, PER, PRV. 2000F_Loop includes TRN, UM, HCR, REF, DTP, SV1 or SV2. This loop can occur in either 2000C at the subscriber level, when the subscriber is the patient, or it can occur at 2000D at the beneficiary level, when a dependent of the subscriber is the patient.

fun createHCR (hcr01)

Creates a HCR segment with provided arguments.

param hcr01 is a string with the action code for HCR.
return X12 formatted HCR segment.

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fhirConstants

This module implements FHIR constants that are used in CoverageEligibilityRequest and Response mapping.

Source: .src/main/resources/dwl/x12Util/fhirConstants.dwl

Functions

fun fhirConstants ()

Gets the constants used in lookup functions.

return A map of constants used.

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x12SegmentQualifiers

This module implements X12 segment qualifier functions.

Source: .src/main/resources/dwl/x12Util/x12SegmentQualifiers.dwl

Functions

fun getSegmentQualifiers ()

Gets the segment qualifiers for the 270 and 837 transactions.

return A map of segment qualifiers.

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