"The PAS Bundle linkId should be used for attached bundles containing resources needed for PAS"

This isn't sufficiently clear.  What we actually need to say is:

"When completing a Questionnaire, it is possible that the CQL logic (or for adaptive forms, the payer) may provide specific resources to be used within the EHR for subsequent processes.  These are provided as "answers" within the QuestionnaireResponse - because that's the only vehicle the payer has to provide information to the EHR and the only means by which the DTR app has to reasonably share the information over current EHR FHIR interfaces.

Specific content that might be returned by the payer include:

• A set of attachments for inclusion in a PAS or other prior authorization request
• A pre-defined PAS prior authorization request Bundle
• An unsolicited prior authorization result
• A set of attachments for inclusion in an insurance claim
• A set of attachments to provide necessary documentation for a post-acute order
• Tasks describing additional workflow steps

The following section defines how this information will be identified within the QuestionnaireResponse, what form the information will take in either Questionnaire or DTR submissions, and what DTR-conformant EHR systems are expected to do with the information.  Note that the QuestionnaireResponse will be tuned to support both QuestionnaireResponse and DocumentReference solutions, as the payer will not know how the EHR will be receiving the information.

NOTE: The special linkIds listed below are reserved and SHALL NOT be used in any payer-authored Questionnaires for any purpose other than as defined here.  Payers SHOULD NOT use linkIds starting with "DTR_" to avoid any collision with potential new special linkIds introduced in future versions of this specification.

PAS attachments

In a QuestionnaireResponse, this will be a 'repeating' question with one or more answers with a linkId of "DTR_PA_ATTACH".  The question type will be 'Reference' and will refer to resources that either exist within the EHR or to 'contained' resources within the QuestionnaireResponse instance.  All of these resources should be included as attachments in the prior authorization request submitted for the order the DTR session is associated with.

In a DocumentReference, there won't be any attachments.  However, the PDF will include a rendered 'display' item for the questionnaire at the end that says "Include this PDF as an attachment within the prior authorization request".  The rendered PDF SHALL include the 'id' of the DocumentReference stored on the payer system such that a human operative working for the payer can then retrieve the payer-stored DocumentReference and the contained QuestionnaireResponse with the actual attachments for electronic processing.

PAS Prior Authorization Bundle

In a QuestionnaireResponse, this will be a question with a single Reference answer with a linkId of "DTR_PAS_BUNDLE".  The Reference will always point to a contained Bundle resource which will be a mostly complete [PAS Bundle], omitting only the EHR-assigned prior authorization identifier, submission date and any other elements that only the submitting EHR could know.  The EHR can choose to use this as the foundation for their prior authorization submission.

In the case where the EHR only receives a PDF DocumentReference, there is no action they can take that will make use of the PAS Bundle.

Unsolicited Prior Authorization

In a QuestionnaireResponse, this will be a question with a single Reference answer with a linkId of "DTR_PRIOR_AUTH".  The Reference will always point to a contained ClaimResponse resource that complies with the [CRD Prior Authorization] profile.  This will contain all of the discrete information needed to understand what has been authorized.  The EHR should transfer this information into their internal prior authorization representation as though the authorization had been retrieved from the payer over traditional channels, associating it with the relevant order(s).

Within the a DocumentReference PDF, there will be a display item that includes all of the prior authorization details as text, including the prior authorization number, billing codes, modifiers, quantities, authorized amount, validity period, etc.  A staff member within the provider organization can then transcribe the authorization information into the appropriate locations within the EHR and/or add it as a notation on the relevant order.

NOTE: Because the record of the prior authorization must reside within the payer system, this can only be included as part of an 'adaptive' QuestionnaireResponse, because in a traditional questionnaire, there is no interaction between the form filling software and the payer.

Claim attachments

In a QuestionnaireResponse, this will be a 'repeating' question with one or more answers with a linkId of "DTR_CLAIM_ATTACH".  The question type will be 'Reference' and will refer to resources that either exist within the EHR or to 'contained' resources within the QuestionnaireResponse instance.  All of these resources should be included as attachments in the insurance claim request submitted for the eventual event(s) fulfilling the order the DTR session is associated with.

In a DocumentReference, there won't be any attachments.  However, the PDF will include a rendered 'display' item for the questionnaire at the end that says "Include this PDF as an attachment within the claim request(s) for this order".  The rendered PDF SHALL include the 'id' of the DocumentReference stored on the payer system such that a human operative working for the payer can then retrieve the payer-stored DocumentReference and the contained QuestionnaireResponse with the actual attachments for electronic processing.

PAO Order attachments

In a QuestionnaireResponse, this will be a 'repeating' question with one or more answers with a linkId of "DTR_PAO_ATTACH".  The question type will be 'Reference' and will refer to resources that either exist within the EHR or to 'contained' resources within the QuestionnaireResponse instance.  [BOB: what should happen here?].

In a DocumentReference, there won't be any attachments.  However, the PDF will include a rendered 'display' item for the questionnaire at the end that says [BOB: what should happen here?]

Additional workflow

(Not sure if we have agreement from the EHRs on this?)

In a QuestionnaireResponse, this will be a 'repeating' question with one or more answers with a linkId of "DTR_TASK".  The question type will be 'Reference' and will refer to contained Task instances that describe workflow actions that need to occur, such as the creation of additional companion orders, pre-execution testing, follow-up orders, etc. These are created when the completion of the questionnaire has made evident that certain workflow steps necessary to satisfy payer requirements were confirmed missing by the user.  The EHR should add 'to do' items to the user's task list that correspond to the actions described within the Task instances.

In a DocumentReference, there won't be any attachments.  However, the PDF will include a rendered 'display' item that describes the additional work that needs to be done.  A staff-person within the EHR should review the instructions and initiate the appropriate workflow actions.

NOTE: It may be appropriate to re-execute the DTR process once the specified tasks have been completed, as the DTR results may change."

The section on SMART Web messaging should be dropped.  There's no interest in it at this time from the EHR vendors and the adopted mechanism described here supersedes it.