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The PDex Prior Authorization profile has been created to enable Payers to communicate prior authorization decisions and changes to the status of a prior authorization to members.

Payers SHALL make available pending and active prior authorization decisions and related clinical documentation and forms for items and services, not including prescription drugs, including the date the prior authorization was approved, the date the authorization ends, as well as the units and services approved and those used to date, no later than one (1) business day after a provider initiates a prior authorization for the beneficiary or there is a change of status for the prior authorization.

A slice has been defined for meta.profile that makes the URI for the Structure Definition a required field. The ExplanationOfBenefit resource is used to express claims information to members in accordance with the Carin Blue Button Implementation Guide. By setting the value of ExplanationOfBenefit.Use to “preauthorization” in Prior Authorization resources a Payer will be able to exclude, or include, Prior Authorization records, dependent upon the use case. For the PDex IG it would be a case of setting “use=preauthorization” as a search parameter to include only Prior Authorization records.

    [BaseURL]/ExplanationOfBenefit?use=preauthorization&patient=Patient/1

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ExplanationOfBenefit

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
meta
Slices for profile		1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile		1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	1..1	CodeableConcept	Category or discipline
use	S	1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient	S	1..1	Reference(US Core Patient Profile(6.1.0))	The recipient of the products and services
enterer	S	0..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0))	Author of the claim
insurer	S	1..1	Reference(US Core Organization Profile(6.1.0))	Party responsible for reimbursement
provider	S	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
facility	S	0..1	Reference(US Core Location Profile(6.1.0))	Servicing Facility
preAuthRefPeriod	S	0..1	Period	Preauthorization in-effect period
careTeam
provider	S	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Practitioner or organization
insurance
coverage		1..1	Reference(HRex Coverage Profile(1.1.0-preview))	Insurance information
item
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier(2.0.1)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
category	S	0..1	CodeableConcept	Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter		0..*	Reference(US Core Encounter Profile(6.1.0))	Encounters related to this billed item
Slices for adjudication		0..*	BackboneElement	Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
amount	S	1..1	Money	Monetary amount
adjudication:allowedunits	S	0..1	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: allowedunits
value	S	1..1	decimal	Non-monitary value
adjudication:denialreason	S	0..*	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: denialreason
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits		0..1	BackboneElement	Adjudication details
category		1..1	CodeableConcept	Type of adjudication 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: consumedunits
value		1..1	decimal	Non-monitary value
addItem
provider		0..*	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Authorized providers
Slices for adjudication	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Header-level adjudication
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
amount		1..1	Money	Monetary amount
adjudication:denialreason	S	0..*		Header-level adjudication
total
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
priorauth-utilization	S	0..1	Quantity, Ratio	An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
category	S	1..1	CodeableConcept	Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.item.category	required	PriorAuthServiceTypeCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes from this IG
ExplanationOfBenefit.item.productOrService	required	PDexPAInstitutionalProcedureCodesVS http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS from this IG
ExplanationOfBenefit.item.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.item.adjudication:denialreason.reason	required	X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG
ExplanationOfBenefit.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.total.category	extensible	PriorAuthorizationAmounts (a valid code from Prior Authorization Values) http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
adjudication-has-amount-type-slice	warning	ExplanationOfBenefit	If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(US Core Patient Profile(6.1.0))	The recipient of the products and services
created	Σ	1..1	dateTime	Response creation date
enterer	S	0..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0))	Author of the claim
insurer	SΣ	1..1	Reference(US Core Organization Profile(6.1.0))	Party responsible for reimbursement
provider	SΣ	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
facility	S	0..1	Reference(US Core Location Profile(6.1.0))	Servicing Facility
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
preAuthRefPeriod	S	0..1	Period	Preauthorization in-effect period
careTeam		0..*	BackboneElement	Care Team members
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Practitioner or organization
insurance	Σ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(HRex Coverage Profile(1.1.0-preview))	Insurance information
item		0..*	BackboneElement	Product or service provided
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier(2.0.1)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
category	S	0..1	CodeableConcept	Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter		0..*	Reference(US Core Encounter Profile(6.1.0))	Encounters related to this billed item
Slices for adjudication		0..*	BackboneElement	Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Adjudication details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
amount	S	1..1	Money	Monetary amount
adjudication:allowedunits	S	0..1	BackboneElement	Adjudication details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: allowedunits
value	S	1..1	decimal	Non-monitary value
adjudication:denialreason	S	0..*	BackboneElement	Adjudication details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: denialreason
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits		0..1	BackboneElement	Adjudication details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. 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: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code		1..1	code	Symbol in syntax defined by the system Fixed Value: consumedunits
value		1..1	decimal	Non-monitary value
Slices for adjudication	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Header-level adjudication
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
amount		1..1	Money	Monetary amount
adjudication:denialreason	S	0..*	See adjudication (ExplanationOfBenefit)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
priorauth-utilization	S	0..1	Quantity, Ratio	An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
amount	Σ	1..1	Money	Financial total for the category
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.item.category	required	PriorAuthServiceTypeCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes from this IG
ExplanationOfBenefit.item.productOrService	required	PDexPAInstitutionalProcedureCodesVS http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS from this IG
ExplanationOfBenefit.item.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.category	example	Pattern: allowedunits http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.category	example	Pattern: denialreason http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.reason	required	X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG
ExplanationOfBenefit.item.adjudication:consumedunits.category	example	Pattern: consumedunits http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.total.category	extensible	PriorAuthorizationAmounts (a valid code from Prior Authorization Values) http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
adjudication-has-amount-type-slice	warning	ExplanationOfBenefit	If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())

Name	Flags	Card.	Type	Description & Constraints
ExplanationOfBenefit	C	0..*	ExplanationOfBenefit	Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
Slices for profile	Σ	1..*	canonical(StructureDefinition)	Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for the resource
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(US Core Patient Profile(6.1.0))	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Response creation date
enterer	S	0..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0))	Author of the claim
insurer	SΣ	1..1	Reference(US Core Organization Profile(6.1.0))	Party responsible for reimbursement
provider	SΣ	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Party responsible for the claim
priority		0..1	CodeableConcept	Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(MedicationRequest | VisionPrescription)	Prescription authorizing services or products
originalPrescription		0..1	Reference(MedicationRequest)	Original prescription if superceded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment Referral
facility	S	0..1	Reference(US Core Location Profile(6.1.0))	Servicing Facility
claim		0..1	Reference(Claim)	Claim reference
claimResponse		0..1	Reference(ClaimResponse)	Claim response reference
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..*	string	Preauthorization reference
preAuthRefPeriod	S	0..1	Period	Preauthorization in-effect period
careTeam		0..*	BackboneElement	Care Team members
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider	S	1..1	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo		0..*	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	Coding	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]		1..1		Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept			CodeableConcept
diagnosisReference			Reference(Condition)
type		0..*	CodeableConcept	Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
precedence		0..1	positiveInt	Precedence (primary, secondary, etc.)
insurance	Σ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
focal	Σ	1..1	boolean	Coverage to be used for adjudication
coverage	Σ	1..1	Reference(HRex Coverage Profile(1.1.0-preview))	Insurance information
preAuthRef		0..*	string	Prior authorization reference number
accident		0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date		0..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x]		0..1		Where the event occurred
locationAddress			Address
locationReference			Reference(Location)
item		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier(2.0.1)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
careTeamSequence		0..*	positiveInt	Applicable care team members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category	S	0..1	CodeableConcept	Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(US Core Encounter Profile(6.1.0))	Encounters related to this billed item
noteNumber		0..*	positiveInt	Applicable note numbers
Slices for adjudication		0..*	BackboneElement	Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount	S	1..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:allowedunits	S	0..1	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: allowedunits
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value	S	1..1	decimal	Non-monitary value
adjudication:denialreason	S	0..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: denialreason
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason	S	1..1	CodeableConcept	Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:consumedunits		0..1	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: consumedunits
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		1..1	decimal	Non-monitary value
detail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Detail level adjudication details
subDetail		0..*	BackboneElement	Additional items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Product or service provided
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subDetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(US Core Practitioner Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core Organization Profile(6.1.0))	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ExplanationOfBenefit)	Added items adjudication
Slices for adjudication	S	0..*	BackboneElement	Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:adjudicationamounttype	S	0..*	BackboneElement	Header-level adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: PDex Adjudication (required)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount		1..1	Money	Monetary amount
value		0..1	decimal	Non-monitary value
adjudication:denialreason	S	0..*	See adjudication (ExplanationOfBenefit)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
priorauth-utilization	S	0..1	Quantity, Ratio	An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		0..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		0..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		0..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
benefitPeriod		0..1	Period	When the benefits are applicable
benefitBalance		0..*	BackboneElement	Balance by Benefit Category
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded		0..1	boolean	Excluded from the plan
name		0..1	string	Short name for the benefit
description		0..1	string	Description of the benefit or services covered
network		0..1	CodeableConcept	In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit		0..1	CodeableConcept	Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term		0..1	CodeableConcept	Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial		0..*	BackboneElement	Benefit Summary
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x]		0..1		Benefits allowed
allowedUnsignedInt			unsignedInt
allowedString			string
allowedMoney			Money
used[x]		0..1		Benefits used
usedUnsignedInt			unsignedInt
usedMoney			Money
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ExplanationOfBenefit.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
ExplanationOfBenefit.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
ExplanationOfBenefit.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.status	required	ExplanationOfBenefitStatus http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1 from the FHIR Standard
ExplanationOfBenefit.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ExplanationOfBenefit.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard
ExplanationOfBenefit.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ExplanationOfBenefit.priority	required	ProcessPriorityCodes http://hl7.org/fhir/ValueSet/process-priority from the FHIR Standard
ExplanationOfBenefit.fundsReserveRequested	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ExplanationOfBenefit.related.relationship	example	ExampleRelatedClaimRelationshipCodes http://hl7.org/fhir/ValueSet/related-claim-relationship from the FHIR Standard
ExplanationOfBenefit.payee.type	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
ExplanationOfBenefit.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ExplanationOfBenefit.careTeam.role	example	ClaimCareTeamRoleCodes http://hl7.org/fhir/ValueSet/claim-careteamrole from the FHIR Standard
ExplanationOfBenefit.careTeam.qualification	example	ExampleProviderQualificationCodes http://hl7.org/fhir/ValueSet/provider-qualification from the FHIR Standard
ExplanationOfBenefit.supportingInfo.category	example	ClaimInformationCategoryCodes http://hl7.org/fhir/ValueSet/claim-informationcategory from the FHIR Standard
ExplanationOfBenefit.supportingInfo.code	example	ExceptionCodes http://hl7.org/fhir/ValueSet/claim-exception from the FHIR Standard
ExplanationOfBenefit.supportingInfo.reason	example	MissingToothReasonCodes http://hl7.org/fhir/ValueSet/missing-tooth-reason from the FHIR Standard
ExplanationOfBenefit.diagnosis.diagnosis[x]	example	ICD-10Codes http://hl7.org/fhir/ValueSet/icd-10 from the FHIR Standard
ExplanationOfBenefit.diagnosis.type	example	ExampleDiagnosisTypeCodes http://hl7.org/fhir/ValueSet/ex-diagnosistype from the FHIR Standard
ExplanationOfBenefit.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission from the FHIR Standard
ExplanationOfBenefit.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup from the FHIR Standard
ExplanationOfBenefit.procedure.type	example	ExampleProcedureTypeCodes http://hl7.org/fhir/ValueSet/ex-procedure-type from the FHIR Standard
ExplanationOfBenefit.procedure.procedure[x]	example	ICD-10ProcedureCodes http://hl7.org/fhir/ValueSet/icd-10-procedures from the FHIR Standard
ExplanationOfBenefit.accident.type	extensible	ActIncidentCode http://terminology.hl7.org/ValueSet/v3-ActIncidentCode
ExplanationOfBenefit.item.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.category	required	PriorAuthServiceTypeCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes from this IG
ExplanationOfBenefit.item.productOrService	required	PDexPAInstitutionalProcedureCodesVS http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS from this IG
ExplanationOfBenefit.item.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.item.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.item.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.item.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.category	example	Pattern: allowedunits http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:allowedunits.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.category	example	Pattern: denialreason http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.reason	required	X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes from this IG
ExplanationOfBenefit.item.adjudication:consumedunits.category	example	Pattern: consumedunits http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ExplanationOfBenefit.item.adjudication:consumedunits.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.item.detail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes http://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ExplanationOfBenefit.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ExplanationOfBenefit.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ExplanationOfBenefit.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ExplanationOfBenefit.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ExplanationOfBenefit.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ExplanationOfBenefit.adjudication.category	required	PDexAdjudicationCategoryDiscriminator http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator from this IG
ExplanationOfBenefit.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.adjudication:adjudicationamounttype.category	required	PDexAdjudication http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ExplanationOfBenefit.total.category	extensible	PriorAuthorizationAmounts (a valid code from Prior Authorization Values) http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts from this IG
ExplanationOfBenefit.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard
ExplanationOfBenefit.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ExplanationOfBenefit.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
ExplanationOfBenefit.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard
ExplanationOfBenefit.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ExplanationOfBenefit.benefitBalance.category	example	BenefitCategoryCodes http://hl7.org/fhir/ValueSet/ex-benefitcategory from the FHIR Standard
ExplanationOfBenefit.benefitBalance.network	example	NetworkTypeCodes http://hl7.org/fhir/ValueSet/benefit-network from the FHIR Standard
ExplanationOfBenefit.benefitBalance.unit	example	UnitTypeCodes http://hl7.org/fhir/ValueSet/benefit-unit from the FHIR Standard
ExplanationOfBenefit.benefitBalance.term	example	BenefitTermCodes http://hl7.org/fhir/ValueSet/benefit-term from the FHIR Standard
ExplanationOfBenefit.benefitBalance.financial.type	example	BenefitTypeCodes http://hl7.org/fhir/ValueSet/benefit-type from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
adjudication-has-amount-type-slice	warning	ExplanationOfBenefit	If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())