臺灣癌症用藥事前審查實作指引
1.0.0 - release

This page is part of the 臺灣癌症用藥事前審查實作指引(TWPAS IG) (v1.0.0: Release) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.0.4. For a full list of available versions, see the Directory of published versions

Resource Profile: 事前審查-Claim TWPAS

Official URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/Claim-twpas Version: 1.0.0
Active as of 2024-10-09 Computable Name: ClaimTWPAS

此事前審查-Claim TWPAS Profile說明本IG如何進一步定義FHIR的Claim Resource以呈現癌藥事前審查之內容

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim C 0..* Claim Claim, Pre-determination or Pre-authorization
sequence-1: diagnosis.sequence一定會有一個「1」,且只能出現一次。
supportingInfo: 至少還需提供檢查報告、影像報告、基因資訊中任一樣資訊。
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... encounter S 1..1 Reference(就醫科別-Encounter TWPAS) 就醫科別,為細分科之就醫科別,作為審查分科用。【此為參考Da Vinci PAS IG的extension設計】
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claim-encounter
... identifier S 0..1 Identifier 原受理編號,若申報類別為申復,則填寫原送核階段受理編號。
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... subType S 1..1 CodeableConcept 申報類別,1:送核 | 2:送核補件 | 3:申復 | 4:爭議審議 | 5:申復補件 。
Binding: NHI-申報類別值集 (required)
... use 1..1 code claim | preauthorization | predetermination
Required Pattern: preauthorization
... patient S 1..1 Reference(病人資訊-Patient TWPAS) 病人資訊
... created S 1..1 dateTime 申請日期,YYYY-MM-DD,機構自填,健保署收案後另建受理日期。
... enterer S 1..1 Reference(醫事人員-Practitioner TWPAS) 申請醫師,必須存在於醫事人員基本資料檔內,並於合約生效起迄日內。
... provider S 1..1 Reference(醫事機構-Organization TWPAS) 醫事機構代碼,必須存在於醫事機構基本資料檔內。
... priority S 1..1 CodeableConcept 申請案件類別,1:一般事前審查申請 | 3:自主審查報備 | 4:緊急報備;專審系統識別用,對應PXXT_CODE(TMHB,001)。
Binding: NHI-申請案件類別值集 (required)
... Slices for supportingInfo 2..* BackboneElement Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... category 1..1 CodeableConcept Classification of the supplied information
Binding: NHI-補充資訊類別值集 (required)
.... supportingInfo:weight 1..1 BackboneElement 病人體重
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: weight
..... timing[x] 0..0
..... value[x] S 1..1 Quantity Data to be provided
...... value SC 1..1 decimal 體重,整數至多3位數及小數至多2位數。
HTWT: 整數至多3位數及小數至多2位數
...... system 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code 1..1 code Coded form of the unit
Required Pattern: kg
.... supportingInfo:height 1..1 BackboneElement 病人身高
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: height
..... timing[x] 0..0
..... value[x] S 1..1 Quantity Data to be provided
...... value SC 1..1 decimal 身高(cm),整數至多3位數及小數至多2位數。
HTWT: 整數至多3位數及小數至多2位數
...... system 1..1 uri System that defines coded unit form
Required Pattern: http://unitsofmeasure.org
...... code 1..1 code Coded form of the unit
Required Pattern: cm
.... supportingInfo:pregnancy 0..1 BackboneElement 是否懷孕或哺乳
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: pregnancyBreastfeedingStatus
..... timing[x] 0..0
..... value[x] S 1..1 boolean 是否懷孕或哺乳,false:未懷孕或哺乳 | true:有懷孕或哺乳
.... supportingInfo:imagingReport 0..* BackboneElement 影像報告
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: imagingReport
..... timing[x] 0..0
..... value[x] S 1..1 Reference(影像報告-DiagnosticReport Image TWPAS) 影像報告
.... supportingInfo:cancerStage 0..* BackboneElement 癌症分期量表
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: cancerStage
..... timing[x] 0..0
..... value[x] S 1..1 Reference(癌症分期量表-Observation Cancer Stage TWPAS) 癌症分期量表
.... supportingInfo:examinationReport 0..* BackboneElement 檢查報告
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: examinationReport
..... timing[x] 0..0
..... value[x] S 1..1 Reference(檢查報告-DiagnosticReport TWPAS) 檢查報告
.... supportingInfo:companionDiagnostics 0..* BackboneElement 基因資訊
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: companionDiagnostics
..... timing[x] 0..0
..... value[x] S 1..1 Reference(基因資訊-Observation Diagnostic TWPAS) 基因資訊
.... supportingInfo:tests 0..* BackboneElement 檢驗(查)
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: tests
..... timing[x] 0..0
..... value[x] S 1..1 Reference(檢驗檢查-Observation Laboratory Result TWPAS) 檢驗(查)
.... supportingInfo:patientAssessment 0..* BackboneElement 病人狀態評估
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: patientAssessment
..... timing[x] 0..0
..... value[x] S 1..1 Reference(病人狀態評估-Observation Patient Assessment TWPAS) 病人狀態評估
.... supportingInfo:medicationRequest 0..* BackboneElement 用藥品項
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicationRequest
..... timing[x] 0..0
..... value[x] S 1..1 Reference(用藥品項-MedicationRequest Treat TWPAS) 用藥品項
.... supportingInfo:radiotherapy 0..* BackboneElement 放射治療
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: radiotherapy
..... timing[x] 0..0
..... value[x] S 1..1 Reference(放射治療-Procedure TWPAS) 放射治療
.... supportingInfo:carePlanDocument 0..* BackboneElement 治療計畫文件,P-IO(免疫檢查點抑制劑治療計畫)、P-CART(CAR-T多團隊會議紀錄)、P-STEMCELL(造血幹細胞移植計畫書),附件形式PDF
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: carePlanDocument
..... timing[x] 0..0
..... value[x] S 1..1 Reference(文件參照-DocumentReference TWPAS) 治療計畫文件
.... supportingInfo:medicalRecord 0..* BackboneElement 病歷資料(非屬影像報告檢查驗報告部分)
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: medicalRecord
..... timing[x] 0..0
..... value[x] S 1..1 Reference(文件參照-DocumentReference TWPAS) Data to be provided
.... supportingInfo:treatmentAssessment 0..* BackboneElement 結果資訊
..... category 1..1 CodeableConcept Classification of the supplied information
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-supporting-info-type
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: treatmentAssessment
..... timing[x] 0..0
..... value[x] S 1..1 Reference(治療後疾病狀態評估-Observation Treatment Assessment TWPAS) 結果資訊
... diagnosis SC 1..* BackboneElement sequence=1時為主要疾病;sequence>=2代表共病。
diagnosis: diagnosis.sequence=1時才需填寫診斷日期、簡要病摘(申請原因)
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... recordedDate S 0..* date 診斷日期,sequence=1時為必填,表示為用藥事前審查之主要疾病;其他共病不須填寫診斷日期。YYYY-MM-DD,西元年月日。【此為參考Da Vinci PAS IG的extension設計】
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... sequence 1..1 positiveInt sequence=1時為主要疾病;sequence>=2代表共病。
.... diagnosis[x] S 1..1 CodeableConcept 國際疾病分類代碼(含共病),當前疾病狀態。ICD-10-CM。
Binding: 臺灣健保署2021年中文版ICD-10-CM值集 (required)
.... type 0..1 CodeableConcept Timing or nature of the diagnosis
..... text S 0..1 string 簡要病摘(申請理由)。連結院內HIS系統之簡要病摘,或填寫原事前審查之申請理由。
... procedure
.... date S 1..1 dateTime 手術(或其他處置)日期
.... procedure[x] S 1..1 CodeableConcept 手術(或其他處置)項目,經動脈導管肝臟腫瘤化學栓塞術(TACE)及冷凍療法等非屬手術。ICD-10-PCS 或 健保代碼 或 其他。
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (example)
..... Slices for coding 1..1 Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
...... coding:icd10-pcs-2021 S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署2021年中文版ICD-10-PCS值集 (required)
...... coding:medical-service-payment S 0..1 Coding Code defined by a terminology system
Binding: 臺灣健保署醫療服務給付項目-處置或手術值集 (required)
... insurance
.... sequence 1..1 positiveInt Insurance instance identifier
Required Pattern: 1
.... coverage 1..1 Reference(健保事前審查計畫-Coverage TWPAS) Insurance information
... item 1..1 BackboneElement Product or service provided
.... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
..... requestedService S 1..* Reference(事前審查品項-MedicationRequest Apply TWPAS) 事前審查品項【此為參考Da Vinci PAS IG的extension設計】
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-requestedService
.... productOrService S 1..1 CodeableConcept 醫令類別。【此欄位為FHIR必填欄位】
Binding: NHI-醫令類別值集 (required)
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-order-type
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 4
.... Slices for modifier 1..2 CodeableConcept Product or service billing modifiers
Slice: Unordered, Open by value:coding.system
..... modifier:continuation S 1..1 CodeableConcept 續用註記,1:初次使用 | 2:申請再次使用
Binding: NHI-續用註記值集 (required)
...... coding 1..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-continuation-status
....... code 1..1 code 1:初次使用 | 2:申請再次使用
..... modifier:lot S 0..1 CodeableConcept 用藥線別,0:不適用 | 1:第一線治療 | 2:第二線治療 | 3:第三線治療 | 4:第四線治療 | 5:第五線治療
Binding: NHI-用藥線別值集 (required)
...... coding 1..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Required Pattern: https://nhicore.nhi.gov.tw/pas/CodeSystem/nhi-line-of-therapy
....... code S 1..1 code 0:不適用 | 1:第一線治療 | 2:第二線治療 | 3:第三線治療 | 4:第四線治療 | 5:第五線治療
.... programCode S 1..1 CodeableConcept 給付適應症條件,藥品給付規定內所規範之適應症或條件,若有特定事前審查品項代碼應以代碼填報。
..... coding 0..* Coding 事前審查品項代碼為KC009612B5、KC010892B5、KC011112DE、KC011162B5、KC011362B5才可填寫。
Binding: NHI-給付適應症值集 (required)
..... text 0..1 string 事前審查品項代碼不為KC009612B5、KC010892B5、KC011112DE、KC011162B5、KC011362B5時,請自行輸入文字。
.... bodySite 0..1 CodeableConcept 申請部位,R:右側 | L:左側 | B:兩側。(此專案暫不檢核,未來待確認)
Binding: NHI-申請部位值集 (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
Claim.subTyperequiredNHIApplyType (a valid code from NHI-申報類別)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-apply-type
from this IG
Claim.priorityrequiredNHITMHBType (a valid code from NHI-申請案件類別)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-tmhb-type
from this IG
Claim.supportingInfo.categoryrequiredNHIPASSupportingInfoType (a valid code from NHI-補充資訊類別)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-supporting-info-type
from this IG
Claim.diagnosis.diagnosis[x]requiredTW2021ICD10CM
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-cm-2021-tw
Claim.procedure.procedure[x]exampleTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Claim.procedure.procedure[x].coding:icd10-pcs-2021requiredTW2021ICD10PCS
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/icd-10-pcs-2021-tw
Claim.procedure.procedure[x].coding:medical-service-paymentrequiredTWMedicalServicePayment
https://twcore.mohw.gov.tw/ig/twcore/ValueSet/procedure-tw
Claim.item.productOrServicerequiredPattern: 4
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-order-type
from this IG
Claim.item.modifier:continuationrequiredNHIContinuationStatus (a valid code from NHI-續用註記)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-continuation-status
from this IG
Claim.item.modifier:lotrequiredNHILOT (a valid code from NHI-用藥線別)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-line-of-therapy
from this IG
Claim.item.programCode.codingrequiredNHIApplyReason (a valid code from NHI-給付適應症)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-apply-reason
from this IG
Claim.item.bodySiterequiredNHIApplySide (a valid code from NHI-申請部位)
https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-apply-side
from this IG

Constraints

IdGradePath(s)DetailsRequirements
HTWTerrorClaim.supportingInfo:weight.value[x].value, Claim.supportingInfo:height.value[x].value整數至多3位數及小數至多2位數
: value.toString().matches('^[0-9]{1,3}(.[0-9]{1,2})?$')
diagnosiserrorClaim.diagnosisdiagnosis.sequence=1時才需填寫診斷日期、簡要病摘(申請原因)
: sequence=1 implies (extension.where(url = 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate').value.ofType(date).exists() and type.text.exists() )
sequence-1errorClaimdiagnosis.sequence一定會有一個「1」,且只能出現一次。
: diagnosis.where(sequence = 1).count() = 1
supportingInfoerrorClaim至少還需提供檢查報告、影像報告、基因資訊中任一樣資訊。
: supportingInfo.category.exists(coding.code = 'examinationReport') or supportingInfo.category.exists(coding.code = 'imagingReport') or supportingInfo.category.exists(coding.code = 'companionDiagnostics')

 

Other representations of profile: CSV, Excel, Schematron

Notes:

以下概述了此Profile所需的RESTful FHIR互動功能。有關TWPAS支援的RESTful互動功能的完整清單,請參閱TWPAS Server能力聲明

建議應該支援以下查詢參數:

  1. 必須(SHALL) 支援透過查詢參數 identifier 查詢所有Claim:
    (如何透過token查詢)
    GET [base]/Claim?identifier=[code]

    例子:
    (1) GET [base]/Claim?identifier=20240831010109051701

  2. 必須(SHALL) 支援透過查詢參數 patient 查詢所有Claim:
    (如何透過reference查詢)
    GET [base]/Claim?patient={Type/}[id]

    例子:
    (1) GET [base]/Claim?patient=Patient/pat-min (2) GET [base]/Claim?patient=pat-min

  3. 必須(SHALL) 支援透過查詢參數 func-type 查詢所有Claim:
    (如何透過reference查詢)
    GET [base]/Claim?func-type={Type/}[id]

    例子:
    (1) GET [base]/Claim?func-type=Encounter/enc-min (2) GET [base]/Claim?func-type=enc-min