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    • Icon: Change Request Change Request
    • Resolution: Not Persuasive
    • Icon: Medium Medium
    • US Da Vinci PAS (FHIR)
    • 0.1 [deprecated]
    • Financial Mgmt
    • (profiles) [deprecated]
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      The payer should have sufficient information based on the item ordered and the diagnoses code(s) to determine which rules to execute.  Since the approval is for the device the only real question is does it meet one or more of the medical necessity rules for coverage.

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      The payer should have sufficient information based on the item ordered and the diagnoses code(s) to determine which rules to execute.  Since the approval is for the device the only real question is does it meet one or more of the medical necessity rules for coverage.
    • Bob Dieterle / Dave Hill : 18-0-2

    Description

      When a PriorAuthorization request is made we have a request with a system and a code. The payer needs to use this information to run specific rules and compute a disposition.

      However, it has been discovered that the (system, code) pair is not unique for a request. One such example is (https://bluebutton.cms.gov/resources/codesystem/hcpcs, E0470) which can be used for Respiratory Assist Device or as a Positive Airway Pressure Device. In the CRD RI a request to this pair would yield two CDS cards with different documentation required. 

      Once this request is submitted to Prior Auth the documentation will be different depending on which use was requested. Using the system and code is therefore not enough to provide a unique mapping from the request to a specific rule file. 

      We need to determine someway so the PASClaim can include this information allowing the PAS server to determine which rules to execute for the request.

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            blangley Benjamin Langley (Inactive)
            Benjamin Langley (Inactive)
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