Da Vinci Payer Data Exchange
2.2.1 - STU 2.2
Da Vinci Payer Data Exchange
2.2.1 - STU 2.2
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 2.2.1 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
| Official URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization | Version: 2.2.1 | |||
| Standards status: Informative | Computable Name: PdexPriorAuthorization | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.8.42.36 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
||||
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. §pdex-395
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
Note on use as a search parameter. ExplanationOfBenefit.use is an element of the FHIR R4 ExplanationOfBenefit resource, but it is not one of the base R4 ExplanationOfBenefit search parameters, and it is not enumerated in the PDex Server CapabilityStatement ExplanationOfBenefit search parameters. The ?use=preauthorization example above is illustrative of the conceptual filter and assumes a server that has chosen to expose use as a custom search parameter. For a portable approach that relies only on parameters listed in the PDex Server CapabilityStatement, clients MAY instead select Prior Authorization records by combining the standard _profile search parameter with patient:
[BaseURL]/ExplanationOfBenefit?_profile=http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization&patient=Patient/1
Where use is not exposed as a server-side search parameter, clients may also retrieve EOBs using the supported parameters and filter by ExplanationOfBenefit.use = preauthorization on the client side. A future version of this IG may formalize a use SearchParameter and add it to the CapabilityStatement; until then, implementers should treat ?use=preauthorization as a non-normative example rather than a conformance expectation.
Linking supporting documentation. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057) requires impacted payers to exchange the structured and unstructured administrative and clinical documentation submitted by providers in support of a prior authorization through the Payer-to-Payer API. This profile does not slice ExplanationOfBenefit.supportingInfo in this STU update, but implementers wishing to associate a Prior Authorization resource with one or more supporting documents (e.g. clinical notes, attachments, signed forms) MAY do so by populating the inherited base R4 element ExplanationOfBenefit.supportingInfo using the conventions below.
additionalInformation concept from the Da Vinci PAS PASSupportingInfoType code system (http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType) on supportingInfo.category to signal that the entry carries supporting documentation. Da Vinci PAS is already a dependency of this IG, so the code system is available without an additional dependency.supportingInfo.value[x] as a valueReference to a DocumentReference resource that describes and locates the supporting document.DocumentReference to be constrained to inline (base64-encoded) content. Either pattern is acceptable, and which to use is a deployment choice:
DocumentReference.content.attachment.data — inline base64 — convenient for small documents that travel in a single payload alongside the EOB.DocumentReference.content.attachment.url — an HTTP(S) URL the receiver can dereference (e.g., a payer-side FHIR endpoint or a pre-signed object-store URL) — appropriate for large documents (for example, attachments exceeding ~10 MB) that should not be inlined into a P2P payload, or for documents that already exist as separately addressable resources.Implementers should choose between inline and URL-referenced content based on the size and lifecycle of the supporting document and on the constraints of the exchange channel. Where the document size is unbounded or material, URL-referenced content is the recommended pattern.
ExplanationOfBenefit.supportingInfo to make the additionalInformation category and Reference(DocumentReference) value pattern conformance-bound (mirroring the Da Vinci PAS profile pattern). Until that work is balloted, the guidance above is informative; servers and clients SHOULD follow it to remain forward-compatible.Representing a requested procedure code range. This profile currently provides a place to express the end of an authorized procedure code range — via the nested PAS extension at item.extension[authorizedItemDetail].extension[productOrServiceCodeEnd] — but no slice on item.extension for the end of a requested procedure code range. item.productOrService holds either a single procedure code or the start of a requested range, with no companion element for the range end. Until a future version of this IG formally adds an item-level productOrServiceCodeEnd slice (likely reusing the same Da Vinci PAS extension-itemAuthorizedDetail.productOrServiceCodeEnd extension definition that this profile already depends on), implementers needing to represent a requested procedure range in PDex Prior Authorization records SHOULD use the following interim pattern:
item entry with the start of the range in item.productOrService (and any other item-level data common to the range).item entry with the end of the range in its item.productOrService.item.extension[itemTraceNumber] on both entries so consumers can group the two item entries as the start and end of a single requested range.item.extension[authorizedItemDetail].extension[productOrServiceCodeEnd] extension — independently of the requested-range expression above.This interim pattern uses only currently-conformant elements and is forward-compatible with a future structural addition. Future direction: a future version of this IG is expected to add a dedicated item-level productOrServiceCodeEnd slice so implementers can express a requested procedure range without duplicating the item entry; until that addition is balloted, the guidance above is informative.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice |
  implicitRules |
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 | |
   extension:levelOfServiceType |
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. | |
 extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | |
 type |
1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | |
| use |
1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization (extensions allowed) | |
 patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
| created |
1..1 | dateTime | Response creation date | |
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim | |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
| facility |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |
| outcome |
1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | |
| preAuthRefPeriod |
0..1 | Period | Preauthorization in-effect period | |
| careTeam |
0..* | BackboneElement | Care Team members | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| sequence |
1..1 | positiveInt | Order of care team | |
 provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization | |
| insurance |
1..* | BackboneElement | Patient insurance information | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| focal |
1..1 | boolean | Coverage to be used for adjudication | |
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | Insurance information | |
| item |
0..* | BackboneElement | Product or service provided | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1)  |
Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |
| extension:previousAuthorizationNumber |
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 | |
| extension:administrationReferenceNumber |
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 | |
| extension:authorizedItemDetail |
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 | |
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| category |
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(7.0.0)) | Encounters related to this billed item | |
  Slices for adjudication |
0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
   adjudication:All Slices |
Content/Rules for all slices | |||
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| modifierExtension |
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 |
0..* | BackboneElement | Adjudication details | |
 modifierExtension |
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:allowedunits |
0..1 | BackboneElement | Adjudication details | |
| modifierExtension |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |
| modifierExtension |
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: | |
| reason |
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 |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| Slices for adjudication |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |
| modifierExtension |
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: | |
| reason |
1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | |
| total |
0..* | BackboneElement | Adjudication totals | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:priorauth-utilization |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| category |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |
| amount |
1..1 | Money | Financial total for the category | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:consumedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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())
|
This structure is derived from ExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-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 (extensions allowed) | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:levelOfServiceType |
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. | |
| extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |
| status |
1..1 | code | active | cancelled | draft | entered-in-error | |
| type |
1..1 | CodeableConcept | Category or discipline | |
| use |
1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization (extensions allowed) | |
| patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim | |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
| facility |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |
| preAuthRefPeriod |
0..1 | Period | Preauthorization in-effect period | |
| careTeam |
||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization | |
| insurance |
||||
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | Insurance information | |
| item |
||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |
| extension:previousAuthorizationNumber |
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 | |
| extension:administrationReferenceNumber |
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 | |
| extension:authorizedItemDetail |
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 | |
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |
| category |
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(7.0.0)) | Encounters related to this billed item | |
| Slices for adjudication |
0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
| adjudication:adjudicationamounttype |
0..* | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
| amount |
1..1 | Money | Monetary amount | |
| adjudication:allowedunits |
0..1 | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| value |
1..1 | decimal | Non-monitary value | |
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| reason |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| addItem |
||||
| provider |
0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers | |
| Slices for adjudication |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
| adjudication:adjudicationamounttype |
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 |
0..* | BackboneElement | Header-level adjudication | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| reason |
1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | |
| total |
||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:priorauth-utilization |
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 |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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 Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
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 |
0..1 | id | Version specific identifier | |||||
| lastUpdated |
0..1 | instant | When the resource version last changed | |||||
| source |
0..1 | uri | Identifies where the resource comes from | |||||
| 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 (extensions allowed) | |||||
| security |
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| tag |
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 |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:levelOfServiceType |
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. | |||||
| extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business Identifier for the resource | |||||
| status |
1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | |||||
| type |
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 |
1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization (extensions allowed) | |||||
| patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |||||
| billablePeriod |
0..1 | Period | Relevant time frame for the claim | |||||
| created |
1..1 | dateTime | Response creation date | |||||
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |||||
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
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 |
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 |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |||||
| claim |
0..1 | Reference(Claim) | Claim reference | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Claim response reference | |||||
| outcome |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
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 |
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 |
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 |
1..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | 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 |
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 (3.0.0) (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 | |||||
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1) |
Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |||||
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |||||
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |||||
| extension:previousAuthorizationNumber |
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 | |||||
| extension:administrationReferenceNumber |
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 | |||||
| extension:authorizedItemDetail |
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 | |||||
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |||||
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |||||
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |||||
| modifierExtension |
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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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(7.0.0)) | 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 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 | |||||
| extension:reviewAction |
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 | |||||
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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:allowedunits |
0..1 | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| 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 | |||||
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| reason |
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 |
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: | |||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 | |||||
| extension:reviewAction |
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 | |||||
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| reason |
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 | |||||
| total |
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 | |||||
| extension:priorauth-utilization |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| category |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |||||
| amount |
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 |
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 |
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.
| |||||
| 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 |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.accident.type | Base | extensible | ActIncidentCode | 📍3.0.0 | THO v7.2 |
| ExplanationOfBenefit.item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:allowedunits.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:consumedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:consumedunits.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| ExplanationOfBenefit.payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.financial.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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())
|
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 0 element(8 nested mandatory elements)
Must-Support: 39 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice |
| implicitRules |
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 | |
| extension:levelOfServiceType |
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. | |
| extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| status |
1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | |
| type |
1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | |
| use |
1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization (extensions allowed) | |
| patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
| created |
1..1 | dateTime | Response creation date | |
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim | |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
| facility |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |
| outcome |
1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | |
| preAuthRefPeriod |
0..1 | Period | Preauthorization in-effect period | |
| careTeam |
0..* | BackboneElement | Care Team members | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| sequence |
1..1 | positiveInt | Order of care team | |
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization | |
| insurance |
1..* | BackboneElement | Patient insurance information | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| focal |
1..1 | boolean | Coverage to be used for adjudication | |
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | Insurance information | |
| item |
0..* | BackboneElement | Product or service provided | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1) |
Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |
| extension:previousAuthorizationNumber |
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 | |
| extension:administrationReferenceNumber |
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 | |
| extension:authorizedItemDetail |
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 | |
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| sequence |
1..1 | positiveInt | Item instance identifier | |
| category |
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(7.0.0)) | Encounters related to this billed item | |
| Slices for adjudication |
0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| modifierExtension |
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 |
0..* | BackboneElement | Adjudication details | |
| modifierExtension |
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:allowedunits |
0..1 | BackboneElement | Adjudication details | |
| modifierExtension |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |
| modifierExtension |
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: | |
| reason |
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 |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| Slices for adjudication |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |
| modifierExtension |
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: | |
| reason |
1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | |
| total |
0..* | BackboneElement | Adjudication totals | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:priorauth-utilization |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| category |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |
| amount |
1..1 | Money | Financial total for the category | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:consumedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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())
|
Differential View
This structure is derived from ExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-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 (extensions allowed) | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:levelOfServiceType |
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. | |
| extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |
| status |
1..1 | code | active | cancelled | draft | entered-in-error | |
| type |
1..1 | CodeableConcept | Category or discipline | |
| use |
1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization (extensions allowed) | |
| patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim | |
| priority |
0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
| facility |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |
| preAuthRefPeriod |
0..1 | Period | Preauthorization in-effect period | |
| careTeam |
||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization | |
| insurance |
||||
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | Insurance information | |
| item |
||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |
| extension:previousAuthorizationNumber |
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 | |
| extension:administrationReferenceNumber |
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 | |
| extension:authorizedItemDetail |
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 | |
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |
| category |
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(7.0.0)) | Encounters related to this billed item | |
| Slices for adjudication |
0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
| adjudication:adjudicationamounttype |
0..* | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
| amount |
1..1 | Money | Monetary amount | |
| adjudication:allowedunits |
0..1 | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| value |
1..1 | decimal | Non-monitary value | |
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| reason |
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: | |
| value |
1..1 | decimal | Non-monitary value | |
| addItem |
||||
| provider |
0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers | |
| Slices for adjudication |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| adjudication:All Slices |
Content/Rules for all slices | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reviewAction |
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 | |
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
| adjudication:adjudicationamounttype |
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 |
0..* | BackboneElement | Header-level adjudication | |
| category |
1..1 | CodeableConcept | Type of adjudication information Required Pattern: | |
| reason |
1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | |
| total |
||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:priorauth-utilization |
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 |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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())
|
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| ExplanationOfBenefit |
C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
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 |
0..1 | id | Version specific identifier | |||||
| lastUpdated |
0..1 | instant | When the resource version last changed | |||||
| source |
0..1 | uri | Identifies where the resource comes from | |||||
| 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 (extensions allowed) | |||||
| security |
0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| tag |
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 |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:levelOfServiceType |
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. | |||||
| extension:claimResponseReviewer |
0..1 | (Complex) | Reviewer practitioner who acted on the prior authorization request (PAS 2.2.1, FHIR-57521) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
0..* | Identifier | Business Identifier for the resource | |||||
| status |
1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | |||||
| type |
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 |
1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization (extensions allowed) | |||||
| patient |
1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services | |||||
| billablePeriod |
0..1 | Period | Relevant time frame for the claim | |||||
| created |
1..1 | dateTime | Response creation date | |||||
| enterer |
0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim | |||||
| insurer |
1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement | |||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
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 |
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 |
0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility | |||||
| claim |
0..1 | Reference(Claim) | Claim reference | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Claim response reference | |||||
| outcome |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| sequence |
1..1 | positiveInt | Order of care team | |||||
| provider |
1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
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 |
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 |
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 |
1..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(HRex Member Match Coverage Profile(1.2.0)) | 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 |
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 (3.0.0) (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 | |||||
| extension:itemTraceNumber |
0..* | PASIdentifier(2.2.1) |
Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | |||||
| extension:preAuthIssueDate |
0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | |||||
| extension:preAuthPeriod |
0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | |||||
| extension:previousAuthorizationNumber |
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 | |||||
| extension:administrationReferenceNumber |
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 | |||||
| extension:authorizedItemDetail |
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 | |||||
| extension:authorizedProvider |
0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | |||||
| extension:admissionDates |
0..1 | date | Authorized admission dates for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates | |||||
| extension:dischargeDate |
0..1 | date | Authorized discharge date for inpatient prior authorization (PAS 2.2.1, FHIR-57521). URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate | |||||
| modifierExtension |
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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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(7.0.0)) | 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 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 | |||||
| extension:reviewAction |
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 | |||||
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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:allowedunits |
0..1 | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| 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 | |||||
| adjudication:denialreason |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| reason |
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 |
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: | |||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | 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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
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 |
C | 0..1 | SimpleQuantity(4.0.1) | Count of products or services Constraints: sqty-1 | ||||
| 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 |
0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 | |||||
| extension:reviewAction |
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 | |||||
| extension:adjudicationActionDate |
0..1 | dateTime | The date/time when an Adjudication Action occurred. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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 |
0..* | BackboneElement | Header-level adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
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: | |||||
| reason |
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 | |||||
| total |
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 | |||||
| extension:priorauth-utilization |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| category |
1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | |||||
| amount |
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 |
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 |
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.
| |||||
| 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 |
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 |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| ExplanationOfBenefit.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.use | Base | required | Use | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std. |
| ExplanationOfBenefit.fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.accident.type | Base | extensible | ActIncidentCode | 📍3.0.0 | THO v7.2 |
| ExplanationOfBenefit.item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:allowedunits.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.item.adjudication:consumedunits.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.adjudication:consumedunits.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.item.detail.subDetail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | Base | required | PDex Adjudication | 📦2.2.1 | This IG |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.adjudication:denialreason.reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.2.1 | This IG |
| ExplanationOfBenefit.total.category | Base | extensible | Prior Authorization value categories | 📦2.2.1 | This IG |
| ExplanationOfBenefit.payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std. |
| ExplanationOfBenefit.benefitBalance.financial.type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| 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())
|
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 0 element(8 nested mandatory elements)
Must-Support: 39 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pdex#2.2.1 based on FHIR 4.0.1. Generated 2026-11-06
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change