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

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

Resource Profile: PDex Prior Authorization

Official URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization Version: 2.1.0
Active as of 2024-03-01 Computable Name: PdexPriorAuthorization

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

Previous Page - US Core PractitionerRole

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

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

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

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

Usage:

Formal Views of Profile Content

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

This structure is derived from ExplanationOfBenefit

NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
... meta
.... Slices for profile 1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... type S1..1CodeableConceptCategory or discipline
... use S1..1codeclaim | preauthorization | predetermination
Required Pattern: preauthorization
... patient S1..1Reference(US Core Patient Profile)The recipient of the products and services
... enterer S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Author of the claim
... insurer S1..1Reference(US Core Organization Profile)Party responsible for reimbursement
... provider S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... facility S0..1Reference(US Core Location Profile)Servicing Facility
... preAuthRefPeriod S0..1PeriodPreauthorization in-effect period
... careTeam
.... provider S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
... insurance
.... coverage 1..1Reference(HRex Coverage Profile)Insurance information
... item
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... category S0..1CodeableConceptBenefit classification
Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
.... encounter 0..*Reference(US Core Encounter Profile)Encounters related to this billed item
.... Slices for adjudication 0..*BackboneElementAdjudication details
Slice: Unordered, Closed by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization at the line level.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype S0..*BackboneElementAdjudication details
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:allowedunits S0..1BackboneElementAdjudication details
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
...... value S1..1decimalNon-monitary value
..... adjudication:denialreason S0..*BackboneElementAdjudication details
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
..... adjudication:consumedunits 0..1BackboneElementAdjudication details
...... category 1..1CodeableConceptType of adjudication information
Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: consumedunits
...... value 1..1decimalNon-monitary value
... addItem
.... provider 0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Authorized providers
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Closed by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization for the entire request.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
..... category S1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementHeader-level adjudication
..... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:denialreason S0..*Header-level adjudication
... total
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... priorauth-utilization S0..1Quantity, RatioAn attribute to express the amount of a service or item that has been utilized
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
.... category S1..1CodeableConceptPrior Authorization utilization codes
Binding: Prior Authorization value categories (extensible)

doco Documentation for this format

Terminology Bindings (Differential)

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

Constraints

IdGradePath(s)DetailsRequirements
adjudication-has-amount-type-slicewarningExplanationOfBenefitIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: preauthorization
... patient SΣ1..1Reference(US Core Patient Profile)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... enterer S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Author of the claim
... insurer SΣ1..1Reference(US Core Organization Profile)Party responsible for reimbursement
... provider SΣ1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... facility S0..1Reference(US Core Location Profile)Servicing Facility
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... preAuthRefPeriod S0..1PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
... insurance Σ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(HRex Coverage Profile)Insurance information
... item 0..*BackboneElementProduct or service provided
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... category S0..1CodeableConceptBenefit classification
Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
.... encounter 0..*Reference(US Core Encounter Profile)Encounters related to this billed item
.... Slices for adjudication 0..*BackboneElementAdjudication details
Slice: Unordered, Closed by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization at the line level.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
..... adjudication:adjudicationamounttype S0..*BackboneElementAdjudication details
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication (required)
...... amount S1..1MoneyMonetary amount
..... adjudication:allowedunits S0..1BackboneElementAdjudication details
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
...... value S1..1decimalNon-monitary value
..... adjudication:denialreason S0..*BackboneElementAdjudication details
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
..... adjudication:consumedunits 0..1BackboneElementAdjudication details
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: consumedunits
...... value 1..1decimalNon-monitary value
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Closed by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization for the entire request.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
.... adjudication:adjudicationamounttype S0..*BackboneElementHeader-level adjudication
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication (required)
..... amount 1..1MoneyMonetary amount
.... adjudication:denialreason S0..*See adjudication (ExplanationOfBenefit)Header-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... priorauth-utilization S0..1Quantity, RatioAn attribute to express the amount of a service or item that has been utilized
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category SΣ1..1CodeableConceptPrior Authorization utilization codes
Binding: Prior Authorization value categories (extensible)
.... amount Σ1..1MoneyFinancial total for the category

doco Documentation for this format

Terminology Bindings

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

Constraints

IdGradePath(s)DetailsRequirements
adjudication-has-amount-type-slicewarningExplanationOfBenefitIf Adjudication is present, it must have at least one adjudicationamounttype slice
: (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. ExplanationOfBenefit C0..*ExplanationOfBenefitExplanation of Benefit resource
adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... Slices for profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
Slice: Unordered, Open by pattern:$this
..... profile:supportedProfile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to

Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for the resource
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Complete, proposed, exploratory, other.


Required Pattern: preauthorization
... patient SΣ1..1Reference(US Core Patient Profile)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer S0..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Author of the claim
... insurer SΣ1..1Reference(US Core Organization Profile)Party responsible for reimbursement
... provider SΣ1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ProcessPriorityCodes (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility S0..1Reference(US Core Location Profile)Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod S0..1PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

... supportingInfo 0..*BackboneElementSupporting information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.

.... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis 0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ICD-10Codes (example): ICD10 Diagnostic codes.

..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.


.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(HRex Coverage Profile)Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.

.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

.... category S0..1CodeableConceptBenefit classification
Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(US Core Encounter Profile)Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... Slices for adjudication 0..*BackboneElementAdjudication details
Slice: Unordered, Closed by pattern:category
..... adjudication:All Slices Content/Rules for all slices
...... id 0..1stringUnique id for inter-element referencing
...... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
...... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization at the line level.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:adjudicationamounttype S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication (required)
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount S1..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:allowedunits S0..1BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: allowedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value S1..1decimalNon-monitary value
..... adjudication:denialreason S0..*BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: denialreason
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason S1..1CodeableConceptExplanation of adjudication outcome
Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monitary value
..... adjudication:consumedunits 0..1BackboneElementAdjudication details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
........ id0..1stringUnique id for inter-element referencing
........ extension0..*ExtensionAdditional content defined by implementations
........ system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
........ version0..1stringVersion of the system - if relevant
........ code1..1codeSymbol in syntax defined by the system
Fixed Value: consumedunits
........ display0..1stringRepresentation defined by the system
........ userSelected0..1booleanIf this coding was chosen directly by the user
....... text0..1stringPlain text representation of the concept
...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 1..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ExplanationOfBenefit)Added items adjudication
... Slices for adjudication S0..*BackboneElementHeader-level adjudication
Slice: Unordered, Closed by pattern:category
.... adjudication:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization for the entire request.
URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: PDex Adjudication Category Discriminator (required)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): Adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... adjudication:adjudicationamounttype S0..*BackboneElementHeader-level adjudication
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*