Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-snapshot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

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Resource Profile: PAS Claim Response Base ( Abstract )

PAS constraints on ClaimResponse resource that are common to both the request and the inquiry.

Usages:

• Derived from this Profile: PAS Claim Inquiry Response, PAS Claim Response, PAS Claim Inquiry Response and PAS Claim Response

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
Slices for extension				Content/Rules for all slices
extension:subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
Slices for extension				Content/Rules for all slices
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome	SΣ	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
Slices for extension				Content/Rules for all slices
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
adjudication	S	0..*	BackboneElement	Header-level adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
processNote	S	0..*	BackboneElement	Note concerning adjudication
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Note instance identifier
text	S	1..1	string	Note explanatory text
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.identifier.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.item.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
system		1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>'
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient	S	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	S	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
Slices for extension				Content/Rules for all slices
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome	S	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
Slices for extension				Content/Rules for all slices
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
adjudication	S	0..*	BackboneElement	Header-level adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
processNote	S	0..*	BackboneElement	Note concerning adjudication
number	S	1..1	positiveInt	Note instance identifier
text	S	1..1	string	Note explanatory text
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation 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:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	More granular claim type 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	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
outcome	SΣ	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item	S	0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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.
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	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	S	1..*	BackboneElement	Added items adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity(4.0.1)	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity(4.0.1)	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication	S	0..*	BackboneElement	Header-level adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..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 adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote	S	0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text	S	1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	S	0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.identifier.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.subType	Base	example	Example Claim SubType Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.request.​type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.payeeType	Base	example	PayeeType	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​provider.type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​bodySite	Base	example	Oral Site Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​subSite	Base	example	Surface Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.total.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.​type	Base	example	Example Payment Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.​adjustmentReason	Base	example	Payment Adjustment Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.fundsReserve	Base	example	FundsReserve	📍4.0.1	FHIR Std.
ClaimResponse.formCode	Base	example	Forms	📍4.0.1	FHIR Std.
ClaimResponse.processNote.​type	Base	required	NoteType	📍4.0.1	FHIR Std.
ClaimResponse.processNote.​language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Summary

Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 66 elements

Structures

This structure refers to these other structures:

• PAS Identifier (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-identifier|2.2.0-snapshot)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary|2.2.0-snapshot)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer|2.2.0-snapshot)
• PAS Requestor Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor|2.2.0-snapshot)
• PAS PractitionerRole (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole|2.2.0-snapshot)
• PAS Claim (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim|2.2.0-snapshot)
• PAS Practitioner (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner|2.2.0-snapshot)
• PAS Organization Base Profile (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-organization|2.2.0-snapshot)
• PAS Quantity (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-quantity|2.2.0-snapshot)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider|2.2.0-snapshot
• http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath|2.2.0-snapshot

Maturity: 4

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
Slices for extension				Content/Rules for all slices
extension:subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
Slices for extension				Content/Rules for all slices
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome	SΣ	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
Slices for extension				Content/Rules for all slices
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
adjudication	S	0..*	BackboneElement	Header-level adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
processNote	S	0..*	BackboneElement	Note concerning adjudication
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Note instance identifier
text	S	1..1	string	Note explanatory text
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.identifier.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.item.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Differential View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
system		1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>'
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient	S	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	S	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
Slices for extension				Content/Rules for all slices
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome	S	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
Slices for extension				Content/Rules for all slices
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
adjudication	S	0..*	BackboneElement	Header-level adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
processNote	S	0..*	BackboneElement	Note concerning adjudication
number	S	1..1	positiveInt	Note instance identifier
text	S	1..1	string	Note explanatory text
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Snapshot ViewView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse, PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation 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:transmissionIdentifiers	S	0..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
extension:claimResponseReviewer	S	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider	S	0..*	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier(2.2.0-snapshot)	Business Identifier for a claim response
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	More granular claim type 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	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient(2.2.0-snapshot))	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization(2.2.0-snapshot))	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization(2.2.0-snapshot) | PAS PractitionerRole(2.2.0-snapshot))	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim(2.2.0-snapshot))	Id of resource triggering adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:DataAbsentReason	S	0..1	code	unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
outcome	SΣ	1..1	code	complete | error | partial Binding: Claim Response Outcome (required)
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item	S	0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:admissionDates	S	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber	S	0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber	S	0..*	PASIdentifier(2.2.0-snapshot)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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:productOrServiceCodeEnd	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
extension:revenue	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-snapshot) (required)
extension:revenueUnitRateLimit	S	0..1	decimal	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService	S	0..1	Reference(PAS Medication Request(2.2.0-snapshot) | PAS Service Request(2.2.0-snapshot) | PAS Device Request(2.2.0-snapshot) | PAS Nutrition Order(2.2.0-snapshot))	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. 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:certificationType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. 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:category		0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. 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:admissionDates	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
extension:dischargeDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	0..*	Reference(PAS Practitioner(2.2.0-snapshot) | PAS Organization Base Profile(2.2.0-snapshot))	Authorized providers
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension:providerType	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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.
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-snapshot) (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-snapshot) (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	PASQuantity(2.2.0-snapshot)	Count of products or services
unitPrice	S	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	S	1..*	BackboneElement	Added items adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity(4.0.1)	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity(4.0.1)	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication	S	0..*	BackboneElement	Header-level adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..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 adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote	S	0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text	S	1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	S	0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-snapshot) (required)
extension:errorElement	S	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-snapshot) (required)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.identifier.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier.​type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.subType	Base	example	Example Claim SubType Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.request.​type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.0-snapshot	This IG
ClaimResponse.payeeType	Base	example	PayeeType	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​provider.type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​productOrService	Base	required	X12 278 Requested Service Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.0-snapshot	This IG
ClaimResponse.addItem.​programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​bodySite	Base	example	Oral Site Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​subSite	Base	example	Surface Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.​reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.total.​category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.​type	Base	example	Example Payment Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.​adjustmentReason	Base	example	Payment Adjustment Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.fundsReserve	Base	example	FundsReserve	📍4.0.1	FHIR Std.
ClaimResponse.formCode	Base	example	Forms	📍4.0.1	FHIR Std.
ClaimResponse.processNote.​type	Base	required	NoteType	📍4.0.1	FHIR Std.
ClaimResponse.processNote.​language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	required	X12 278 Reject Reason Value Set	📍2.2.0-snapshot	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Summary

Mandatory: 1 element(2 nested mandatory elements)
Must-Support: 66 elements

Structures

This structure refers to these other structures:

• PAS Identifier (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-identifier|2.2.0-snapshot)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary|2.2.0-snapshot)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer|2.2.0-snapshot)
• PAS Requestor Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor|2.2.0-snapshot)
• PAS PractitionerRole (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole|2.2.0-snapshot)
• PAS Claim (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim|2.2.0-snapshot)
• PAS Practitioner (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner|2.2.0-snapshot)
• PAS Organization Base Profile (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-organization|2.2.0-snapshot)
• PAS Quantity (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-quantity|2.2.0-snapshot)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider|2.2.0-snapshot
• http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement|2.2.0-snapshot
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath|2.2.0-snapshot

Maturity: 4