Profile: PASClaimBase Parent: Claim Id: profile-claim-base Title: "PAS Claim Base" Description: "PAS constraints on Claim resource that are common to both the request and the inquiry." * ^abstract = true * . ^short = "Preauthorization" * extension contains TransmissionIdentifiers named transmissionIdentifiers 0..1 MS and LevelOfServiceCode named levelOfServiceType 0..1 MS and ConditionCode named conditionCode 0..* MS and HomeHealthCareInformation named homeHealthCareInformation 0..1 MS and AuthorizationNumber named authorizationNumber 0..1 MS and AdministrationReferenceNumber named administrationReferenceNumber 0..1 MS * extension[levelOfServiceType] ^short = "A code specifying the level of service being requested (UM06)" * extension[conditionCode] ^short = "Used to indicate condition codes for various requests for service." * extension[homeHealthCareInformation] ^short = "Used to provide required information about home health care services. (CR6)" * identifier MS * identifier only PASIdentifier * identifier ^short = "Business identifier for claim" * identifier.system ^short = "SHOULD use a scheme of 'urn:trnorg:'" * status MS * status = #active * status ^short = "This is fixed to active even if the CertificationType is indicating that the Claim is to be cancelled as it reflects that status of this instance and not the overall Claim" * type from ClaimTypes * type ^short = "This is used as a high-level mapping of the X12 UM03 field" * use MS * use = #preauthorization * patient MS * patient only Reference(PASBeneficiary) * insurer 1..1 MS * insurer only Reference(PASInsurer) * provider MS * provider only Reference(PASRequestor or PASPractitionerRole) * careTeam MS * careTeam.sequence MS * careTeam.provider MS * careTeam.provider only Reference(PASOrganization or PASPractitionerRole) * careTeam.role MS * careTeam.qualification MS * careTeam ^slicing.discriminator.type = #value * careTeam ^slicing.discriminator.path = "extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)" * careTeam ^slicing.rules = #open * careTeam ^slicing.description = "Slice based on whether the care team member belongs to the overall claim or to an individual claim item." * careTeam contains OverallClaimMember 0..* MS and ItemClaimMember 0..* MS * careTeam[OverallClaimMember].extension contains CareTeamClaimScope named careTeamClaimScope 1..1 MS * careTeam[OverallClaimMember].extension[careTeamClaimScope].valueBoolean MS * careTeam[OverallClaimMember].extension[careTeamClaimScope].valueBoolean = true (exactly) * careTeam[OverallClaimMember] ^short = "Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request." * careTeam[OverallClaimMember] ^comment = "NOTE: Only the first 14 can be sent in the X12 Request." * careTeam[ItemClaimMember] ^short = "Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request." * careTeam[ItemClaimMember] ^comment = "NOTE: Only the first 10 can be sent in the X12 Request." * careTeam[ItemClaimMember].extension contains CareTeamClaimScope named careTeamClaimScope 1..1 MS * careTeam[ItemClaimMember].extension[careTeamClaimScope].valueBoolean MS * careTeam[ItemClaimMember].extension[careTeamClaimScope].valueBoolean = false (exactly) * careTeam[OverallClaimMember].role MS * careTeam[OverallClaimMember].role from https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required) * careTeam[OverallClaimMember].role ^binding.description = "Codes identifying an organizational 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." * careTeam[OverallClaimMember].qualification MS * careTeam[OverallClaimMember].qualification from https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required) * careTeam[OverallClaimMember].role ^binding.description = "Codes identifying a provider specialty. 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." * careTeam[ItemClaimMember].role from https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required) * careTeam[ItemClaimMember].role ^binding.description = "Codes identifying an organizational 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." * careTeam[ItemClaimMember].qualification MS * careTeam[ItemClaimMember].qualification from https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required) * careTeam[ItemClaimMember].role ^binding.description = "Codes identifying a provider specialty. 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." * careTeam.extension contains CareTeamClaimScope named careTeamClaimScope 1..1 MS * supportingInfo MS * supportingInfo.sequence MS * supportingInfo.category MS * supportingInfo.category from PASSupportingInfoType (extensible) * diagnosis MS * diagnosis.sequence MS * diagnosis.diagnosis[x] MS * diagnosis.diagnosis[x] only CodeableConcept * diagnosis.diagnosisCodeableConcept from X12278DiagnosisCodes (required) * diagnosis.type 0..1 MS * diagnosis.type from X12278DiagnosisType (required) * insurance MS * insurance.sequence MS * insurance.focal = true * insurance.coverage MS * insurance.coverage only Reference(PASCoverage) * accident MS * accident.date MS * accident.date obeys FullDateRule * accident.type MS * accident.type from https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required) * accident.type ^binding.description = "Codes identifying an accompanying cause of an illness, injury or an accident. 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." * accident.location[x] MS * accident.location[x] only Address * item MS * item.extension contains ItemTraceNumber named itemTraceNumber 0..* MS and AuthorizationNumber named authorizationNumber 0..1 MS and AdministrationReferenceNumber named administrationReferenceNumber 0..1 MS and ServiceItemRequestType named requestType 0..1 MS and CertificationType named certificationType 0..1 MS and ProductOrServiceCodeEnd named productOrServiceCodeEnd 0..1 MS * item.extension[itemTraceNumber] ^short = "Uniquely identifies this claim item. (2000F-TRN)" * item.extension[authorizationNumber] ^short = "A string assigned by the UMO to an authorized review outcome associated with this service item." * item.extension[administrationReferenceNumber] ^short = "A string assigned by the UMO to the original disallowed review outcome associated with this service item." * item.extension[requestType] ^short = "A code that identifies the type of service being requested." * item.extension[certificationType] ^short = "A code representing the type of certification being requested (UM02)" * item.extension[productOrServiceCodeEnd] ^short = "Used to provide the last code in a series of codes for the service being requested." * item.sequence MS * ^short = "Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse" * item.careTeamSequence MS * item.diagnosisSequence MS * item.informationSequence MS * item.revenue MS * item.revenue from AHANUBCRevenueCodes (required) * item.category MS * item.category from https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required) * item.category ^binding.description = "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." * item.productOrService MS * item.productOrService from X12278RequestedServiceType (required) * item.modifier MS * item.modifier from X12278RequestedServiceModifierType (required) * item.serviced[x] MS * item.servicedDate MS * item.servicedPeriod MS * item.servicedDate obeys FullDateRule * item.servicedPeriod.start obeys FullDateRule * item.servicedPeriod.end obeys FullDateRule * item.location[x] MS * item.location[x] only CodeableConcept * item.locationCodeableConcept from X12278LocationType (required) * item.quantity MS * item.quantity only PASQuantity * item.quantity ^comment = "For any exchange that must be converted to an X12 request, units SHALL be restricted to international units, days, units, minutes, hours, months, or visits." * supportingInfo ^slicing.discriminator.type = #value * supportingInfo ^slicing.discriminator.path = "category" * supportingInfo ^slicing.rules = #open * supportingInfo ^slicing.description = "Slice based on the different types of supporting information that can be included in a authorization request." * supportingInfo contains PatientEvent 0..1 MS and AdmissionDates 0..1 MS and DischargeDates 0..1 MS * supportingInfo[PatientEvent] ^short = "Information about the dates of the event that are being requested." * supportingInfo[PatientEvent].category = PASTempCodes#patientEvent * supportingInfo[PatientEvent].timing[x] 1..1 MS * supportingInfo[PatientEvent].timingDate MS * supportingInfo[PatientEvent].timingDate obeys FullDateRule * supportingInfo[PatientEvent].timingPeriod MS * supportingInfo[PatientEvent].timingPeriod.start MS * supportingInfo[PatientEvent].timingPeriod.start obeys FullDateRule * supportingInfo[PatientEvent].timingPeriod.end MS * supportingInfo[PatientEvent].timingPeriod.end obeys FullDateRule * supportingInfo[PatientEvent].value[x] 0..0 * supportingInfo[AdmissionDates] ^short = "Information about the admission dates of a hospital admission being requested." * supportingInfo[AdmissionDates].category = PASTempCodes#admissionDates * supportingInfo[AdmissionDates].timing[x] 1..1 MS * supportingInfo[AdmissionDates].timingDate MS * supportingInfo[AdmissionDates].timingDate obeys FullDateRule * supportingInfo[AdmissionDates].timingPeriod MS * supportingInfo[AdmissionDates].timingPeriod.start MS * supportingInfo[AdmissionDates].timingPeriod.start obeys FullDateRule * supportingInfo[AdmissionDates].timingPeriod.end MS * supportingInfo[AdmissionDates].timingPeriod.end obeys FullDateRule * supportingInfo[AdmissionDates].value[x] 0..0 * supportingInfo[DischargeDates] ^short = "Information about the discharge dates of a hospital admission being requested." * supportingInfo[DischargeDates].category = PASTempCodes#dischargeDates * supportingInfo[DischargeDates].timing[x] 1..1 MS * supportingInfo[DischargeDates].timing[x] only date * supportingInfo[DischargeDates].timingDate MS * supportingInfo[DischargeDates].timingDate obeys FullDateRule * supportingInfo[DischargeDates].value[x] 0..0 Profile: PASClaim Parent: PASClaimBase Id: profile-claim Title: "PAS Claim" Description: "PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request" * insert CommonClaimElements * related 0..0 RuleSet: CommonClaimElements * . ^short = "Preauthorization" * extension contains http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter named encounter 0..1 MS * extension[encounter] ^short = "Information about a hospital claim being requested." * extension[encounter].valueReference only Reference(PASEncounter) * identifier 1..2 MS * diagnosis MS * diagnosis.extension contains DiagnosisRecordedDate named recordedDate 0..1 MS * diagnosis.extension[recordedDate] ^short = "The date that a diagnosis was recorded. (HIxx-4)" * item 1..* MS * item.extension contains EPSDTIndicator named epsdtIndicator 0..1 MS and NursingHomeResidentialStatus named nursingHomeResidentialStatus 0..1 MS and NursingHomeLevelOfCare named nursingHomeLevelOfCare 0..1 MS and RevenueUnitRateLimit named revenueUnitRateLimit 0..1 MS and RequestedService named requestedService 0..1 MS * item.extension[requestType] 1..1 * item.extension[certificationType] 1..1 * diagnosis ^short = "Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request." * item.extension[nursingHomeResidentialStatus].valueCodeableConcept MS * item.extension[nursingHomeResidentialStatus].valueCodeableConcept from https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required) * item.extension[nursingHomeResidentialStatus].valueCodeableConcept ^binding.description = "Codes specifying the status of a nursing home resident at the time 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." * item.extension[epsdtIndicator] ^short = "An indicator of whether early and periodic screen for diagnosis and treatment of children is involved." * item.extension[nursingHomeResidentialStatus] ^short = "A code specifying the status of a nursing home resident at the time of service. (SV209)" * item.extension[nursingHomeLevelOfCare] ^short = "A code specifying the level of care provided by a nursing home facility. (SV120, SV210)" * item.extension[revenueUnitRateLimit] ^short = "The limit on the rate per unit of revenue for hospital accomodation. (SV206)" * item.extension[requestedService] ^short = "The details of the service being requested." * item.category 1..1 MS * item.category ^short = "Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request." * item.unitPrice MS * item.location[x] 1..1 * item obeys ImmediateLevelOfCare * supportingInfo contains AdditionalInformation 0..* MS and MessageText 0..* MS * supportingInfo[AdditionalInformation] ^short = "Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed." * supportingInfo[AdditionalInformation].category = PASTempCodes#additionalInformation * supportingInfo[AdditionalInformation].extension contains DocumentInformation named documentInformation 1..1 MS * supportingInfo[AdditionalInformation].timing[x] 0..0 * supportingInfo[AdditionalInformation].value[x] 1..1 MS * supportingInfo[AdditionalInformation].value[x] only Reference( PASDocumentReference or $DTRQRBundle or $USCoreQuestionnaireResponse or $USCoreAllergyIntolerence or $USCoreConditionEncounterDiagnosis or $USCoreConditionProblemsandHealthConcerns or $USCoreDiagnositicReportforLaboratoryResults or $USCoreImmunization or $USCoreMedicationRequest or $USCoreProcedure or $USCoreServiceRequest or $USCoreObservationClinicalResult or $USCoreSimpleObservation or $USCoreVitalSigns or NutritionOrder or DeviceRequest) * supportingInfo[AdditionalInformation].value[x] ^comment = "Although we allow of any type of information to be sent, when sending reference to documents, the US-Core DocumentReference profile SHOULD be used." * supportingInfo[MessageText] ^short = "Send text messages to the UMO." * supportingInfo[MessageText].category = PASTempCodes#freeFormMessage * supportingInfo[MessageText].timing[x] 0..0 * supportingInfo[MessageText].value[x] 1..1 MS * supportingInfo[MessageText].value[x] only string Profile: PASDocumentReference Parent: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference|7.0.0 Id: profile-documentreference Title: "PAS Document Reference" Description: "PAS constraints on US Core DocumentReference to require the document content to be included and not referenced externally." * content.attachment.data 1..1 * content.attachment.url 0..0 Extension: DocumentInformation Id: extension-documentInformation Description: "Information about the document being included such as the type, transmission method, and identifier." * extension contains reportTypeCode 1..1 and transmissionMethod 0..1 and controlNumber 0..1 and description 0..1 * extension[reportTypeCode].value[x] only CodeableConcept * extension[reportTypeCode].valueCodeableConcept from http://hl7.org/fhir/us/davinci-pas/ValueSet/pas-pwk01-attachment-report-type-code (required) * extension[reportTypeCode] ^short = "The type of additional information being provided" * extension[transmissionMethod].value[x] only CodeableConcept * extension[transmissionMethod].valueCodeableConcept from https://valueset.x12.org/x217/005010/request/2000E/PWK/1/02/00/756 (required) * extension[transmissionMethod] ^short = "How the additional information is being provided" * extension[controlNumber].value[x] only string * extension[controlNumber] ^short = "A control number that identifies the document" * extension[description].value[x] only string * extension[description] ^short = "Special information about the additional information provided" * ^context[+].type = #element * ^context[=].expression = "Claim.supportingInfo" Invariant: ImmediateLevelOfCare Description: "If Certification Type is an immediate appeal, then Level of Service Code must be present" Expression: "extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists()" Severity: #error Profile: PASClaimInquiry Parent: PASClaimBase Id: profile-claim-inquiry Title: "PAS Claim Inquiry" Description: "PAS constraints on Claim resource when submitting an inquiry for existing authorizations." * . ^short = "Query for Preauthorizations" * extension contains CertificationType named certificationType 0..1 MS * extension[certificationType] ^short = "A code representing the type of certification being requested (UM02)" * identifier 1..1 MS * provider ^short = "This is the submitter of the inquiry." * billablePeriod MS * diagnosis ^comment = "When multiple diagnoses are sent, the intermediary will need to convert the single inquiry into multiple X12 278 inquiries - one for each diagnosis code - and then make the union of the returned Prior Authorization responses." * item.extension contains CertificationIssueDate named certIssueDate 0..1 MS and CertificationExpirationDate named certExpirationDate 0..1 MS and CertificationEffectiveDate named certEffectiveDate 0..1 MS and ReviewActionCode named reviewActionCode 0..1 MS * item.extension[certIssueDate] ^short = "The specific date or period within when which item's preauthorization was issued." * item.extension[certExpirationDate] ^short = "The specific date or period within which this item's preauthorization expires." * item.extension[certEffectiveDate] ^short = "The specific date or period within which this item's preauthorization became effective." * item.extension[reviewActionCode] ^short = "The code describing the result of the review."