Da Vinci Payer Data Exchange
2.1.0 - STU2 United States of America flag

Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

Resource Profile: PDex Prior Authorization

Official URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization Version: 2.1.0
Active as of 2024-04-19 Computable Name: PdexPriorAuthorization

The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members

Previous Page - US Core PractitionerRole

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

Usage:

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

... 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) The recipient of the products and services
... enterer S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Author of the claim
... insurer S 1..1 Reference(US Core Organization Profile) Party responsible for reimbursement
... provider S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... facility S 0..1 Reference(US Core Location Profile) Servicing Facility
... preAuthRefPeriod S 0..1 Period Preauthorization in-effect period
... careTeam
.... provider S 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) Practitioner or organization
... insurance
.... coverage 1..1 Reference(HRex Coverage Profile) Insurance information
... item
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... itemTraceNumber S 0..* PASIdentifier 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) 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 | US Core PractitionerRole Profile | US Core Organization Profile) 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)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.item.categoryrequiredPriorAuthServiceTypeCodes
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredPDexPAInstitutionalProcedureCodesVS
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS
from this IG
ExplanationOfBenefit.item.adjudication.categoryrequiredPDexAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredPDexAdjudication
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
from this IG
ExplanationOfBenefit.item.adjudication:denialreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.adjudication.categoryrequiredPDexAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredPDexAdjudication
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
from this IG
ExplanationOfBenefit.total.categoryextensiblePriorAuthorizationAmounts (a valid code from Prior Authorization Values)
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts
from this IG

Constraints

IdGradePath(s)DetailsRequirements
adjudication-has-amount-type-slicewarningExplanationOfBenefitIf 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())
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.


... 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) The recipient of the products and services
... created Σ 1..1 dateTime Response creation date
... enterer S 0..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Author of the claim
... insurer SΣ 1..1 Reference(US Core Organization Profile) Party responsible for reimbursement
... provider SΣ 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) Party responsible for the claim
... priority 0..1 CodeableConcept Desired processing urgency
Binding: ProcessPriorityCodes (required)
... facility S 0..1 Reference(US Core Location Profile) 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 | US Core PractitionerRole Profile | US Core Organization Profile) 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) 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 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) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ExplanationOfBenefit.statusrequiredExplanationOfBenefitStatus
http://hl7.org/fhir/ValueSet/explanationofbenefit-status|4.0.1
from the FHIR Standard
ExplanationOfBenefit.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ExplanationOfBenefit.userequiredPattern: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ExplanationOfBenefit.priorityrequiredProcessPriorityCodes
http://hl7.org/fhir/ValueSet/process-priority
from the FHIR Standard
ExplanationOfBenefit.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ExplanationOfBenefit.item.categoryrequiredPriorAuthServiceTypeCodes
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthServiceTypeCodes
from this IG
ExplanationOfBenefit.item.productOrServicerequiredPDexPAInstitutionalProcedureCodesVS
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexPAInstitutionalProcedureCodesVS
from this IG
ExplanationOfBenefit.item.adjudication.categoryrequiredPDexAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.categoryrequiredPDexAdjudication
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
from this IG
ExplanationOfBenefit.item.adjudication:allowedunits.categoryexamplePattern: allowedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.categoryexamplePattern: denialreason
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.item.adjudication:denialreason.reasonrequiredX12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
http://hl7.org/fhir/us/davinci-pdex/ValueSet/X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes
from this IG
ExplanationOfBenefit.item.adjudication:consumedunits.categoryexamplePattern: consumedunits
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ExplanationOfBenefit.adjudication.categoryrequiredPDexAdjudicationCategoryDiscriminator
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudicationCategoryDiscriminator
from this IG
ExplanationOfBenefit.adjudication:adjudicationamounttype.categoryrequiredPDexAdjudication
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PDexAdjudication
from this IG
ExplanationOfBenefit.total.categoryextensiblePriorAuthorizationAmounts (a valid code from Prior Authorization Values)
http://hl7.org/fhir/us/davinci-pdex/ValueSet/PriorAuthorizationAmounts
from this IG

Constraints

IdGradePath(s)DetailsRequirements
adjudication-has-amount-type-slicewarningExplanationOfBenefitIf 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())
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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 BindingsPurpose
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) 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 | US Core PractitionerRole Profile) Author of the claim
... insurer SΣ 1..1 Reference(US Core Organization Profile) Party responsible for reimbursement
... provider SΣ 1..1 Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) 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) 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 | US Core PractitionerRole Profile | US Core Organization Profile) 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) 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 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) 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 | US Core PractitionerRole Profile | US Core Organization Profile) 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