FHIR Development Skill

Description

Build FHIR R4 compliant healthcare interoperability systems. Covers Da Vinci implementation guides (PAS, CRD, DTR), US Core profiles, CMS-0057-F compliance, and SMART on FHIR authorization.

When to Use

• Developing FHIR servers or clients
• Building prior authorization APIs (CMS-0057-F)
• Implementing CDS Hooks for coverage requirements discovery
• Creating or validating FHIR resources
• Mapping between X12 and FHIR representations
• Working toward CMS interoperability rule compliance
• Building Da Vinci PAS, CRD, or DTR implementations

Capabilities

• Resource Building: Construct FHIR R4 resources (Claim, ClaimResponse, Condition, Procedure, Coverage, QuestionnaireResponse, DetectedIssue)
• Profile Validation: Validate resources against Da Vinci PAS, CRD, DTR, and US Core profiles
• Bundle Assembly: Build and parse PAS request/response bundles
• Terminology Mapping: ICD-10 urgency tiers, CPT clinical urgency, X12 278 status codes, CMS denial reason codes
• Compliance Checking: CMS-0057-F compliance checklist with per-requirement validation
• Urgency Assessment: Map diagnosis/procedure codes to clinical urgency classifications

Da Vinci ePA Workflow

The CMS-0057-F mandated prior authorization workflow uses three Da Vinci IGs:

1. CRD (Coverage Requirements Discovery)
   EHR fires CDS Hook at order entry → Payer returns coverage info
   "Is this service covered? Is PA needed? What documentation?"

2. DTR (Documentation, Templates, and Rules)
   Payer sends Questionnaire → Provider completes it
   "Fill out this form with the clinical justification"

3. PAS (Prior Authorization Support)
   Provider submits Claim bundle → Payer returns ClaimResponse
   "Here is the complete PA request" → "Approved/Denied/Pended"

Usage

Build a Prior Authorization Request

from skills.fhir_development import build_pa_request

bundle = build_pa_request(
    patient_id="patient-123",
    diagnosis_codes=["N44.00"],      # Testicular torsion
    procedure_codes=["54600"],        # Orchiopexy
    priority="emergent",
)

Validate a FHIR Resource

from skills.fhir_development import validate_resource

result = validate_resource(claim_response)
if not result["valid"]:
    for error in result["errors"]:
        print(f"  - {error}")

Check CMS-0057-F Compliance

from skills.fhir_development import get_compliance_checklist

checklist = get_compliance_checklist(claim_response)
for item in checklist["items"]:
    status = "PASS" if item["met"] else "FAIL"
    print(f"  [{status}] {item['requirement']}")

Assess Clinical Urgency

from skills.fhir_development import get_urgency_assessment

assessment = get_urgency_assessment(
    diagnosis_codes=["N44.00"],
    procedure_codes=["54600"],
)
# assessment["is_time_critical"] == True
# assessment["max_urgency_tier"] == 2

Relationship to Other Skills

Supported FHIR Profiles

Terminology Support

Triggers

FHIR, HL7, Da Vinci, prior authorization API, CMS-0057, interoperability, healthcare API, CDS Hooks, US Core, ClaimResponse, PAS bundle

Success Criteria

• Generated resources pass profile validation
• PAS bundles conform to Da Vinci IG structure
• CMS-0057-F compliance items are accurately assessed
• Urgency tier mapping matches clinical evidence base