Da Vinci Payer Data Exchange
2.1.1 - STU 2.1

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 2.1.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

## Resource Profile: PDex Prior Authorization ( Experimental )

Official URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization | Version: 2.1.1
Standards status: Informative | Computable Name: PdexPriorAuthorization
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

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

Previous Page - US Core PractitionerRole

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

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

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

Usages:

- Examples for this Profile: ExplanationOfBenefit/PDexPriorAuth1
- CapabilityStatements using this Profile: PDEX Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | S Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
created | Σ | 1..1 | dateTime | Response creation date
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S Σ | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S Σ | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  | 0..* | BackboneElement | Care Team members
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
item |  | 0..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount | S | 1..1 | Money | Monetary amount
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value |  | 1..1 | decimal | Non-monitary value
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount |  | 1..1 | Money | Monetary amount
adjudication:denialreason | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
total | Σ | 0..* | BackboneElement | Adjudication totals
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
amount | Σ | 1..1 | Money | Financial total for the category
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ExplanationOfBenefit | 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 | ExplanationOfBenefit | 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 | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ExplanationOfBenefit | 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()`

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
meta |  |  |  |
Slices for profile |  | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
status | S | 1..1 | code | active | cancelled | draft | entered-in-error
type | S | 1..1 | CodeableConcept | Category or discipline
use | S | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient | S | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  |  |  |
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
insurance |  |  |  |
coverage |  | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
item |  |  |  |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount | S | 1..1 | Money | Monetary amount
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
value |  | 1..1 | decimal | Non-monitary value
addItem |  |  |  |
provider |  | 0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount |  | 1..1 | Money | Monetary amount
adjudication:denialreason | S | 0..* | BackboneElement | Header-level adjudication
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
total |  |  |  |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
category | S | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
Slices for profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional 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:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for the resource
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | S Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | Response creation date
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S Σ | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S Σ | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related |  | 0..* | BackboneElement | Prior or corollary claims
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference |  | 0..1 | Identifier | File or case reference
prescription |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment Referral
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
claim |  | 0..1 | Reference(Claim) | Claim reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..* | string | Preauthorization reference
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role |  | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo |  | 0..* | BackboneElement | Supporting information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Information instance identifier
category |  | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] |  | 1..1 |  | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
insurance | Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
preAuthRef |  | 0..* | string | Prior authorization reference number
accident |  | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date |  | 0..1 | date | When the incident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Where the event occurred
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
item |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
careTeamSequence |  | 0..* | positiveInt | Applicable care team members
diagnosisSequence |  | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
modifier |  | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount | S | 1..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 1..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 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
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(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 |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(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 |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjudicationamounttype | 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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 1..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:denialreason | 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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
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 |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 0..1 | Period | When the benefits are applicable
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.3
ExplanationOfBenefit.​item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:allowedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG
ExplanationOfBenefit.​payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ExplanationOfBenefit | 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 | ExplanationOfBenefit | 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 | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ExplanationOfBenefit | 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()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 0 element(8 nested mandatory elements)
Must-Support: 36 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
- US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
- US Core PractitionerRole Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole)
- US Core Organization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization)
- US Core Location Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-location)
- HRex Member Match Coverage Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of ExplanationOfBenefit.meta.profile
- The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication (Closed)
- The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication (Closed)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | S Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
created | Σ | 1..1 | dateTime | Response creation date
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S Σ | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S Σ | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  | 0..* | BackboneElement | Care Team members
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
insurance | Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
item |  | 0..* | BackboneElement | Product or service provided
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount | S | 1..1 | Money | Monetary amount
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value |  | 1..1 | decimal | Non-monitary value
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount |  | 1..1 | Money | Monetary amount
adjudication:denialreason | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
total | Σ | 0..* | BackboneElement | Adjudication totals
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
amount | Σ | 1..1 | Money | Financial total for the category
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ExplanationOfBenefit | 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 | ExplanationOfBenefit | 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 | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ExplanationOfBenefit | 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

This structure is derived from ExplanationOfBenefit

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
meta |  |  |  |
Slices for profile |  | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
status | S | 1..1 | code | active | cancelled | draft | entered-in-error
type | S | 1..1 | CodeableConcept | Category or discipline
use | S | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient | S | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  |  |  |
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
insurance |  |  |  |
coverage |  | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
item |  |  |  |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount | S | 1..1 | Money | Monetary amount
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
value |  | 1..1 | decimal | Non-monitary value
addItem |  |  |  |
provider |  | 0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
amount |  | 1..1 | Money | Monetary amount
adjudication:denialreason | S | 0..* | BackboneElement | Header-level adjudication
category |  | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
total |  |  |  |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
category | S | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource Constraints: adjudication-has-amount-type-slice
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
Slices for profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this
profile:supportedProfile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional 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:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for the resource
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance.
type | S Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0)) | The recipient of the products and services
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | Response creation date
enterer | S | 0..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0)) | Author of the claim
insurer | S Σ | 1..1 | Reference(US Core Organization Profile(7.0.0)) | Party responsible for reimbursement
provider | S Σ | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Party responsible for the claim
priority |  | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required)
fundsReserveRequested |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related |  | 0..* | BackboneElement | Prior or corollary claims
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
claim |  | 0..1 | Reference(Claim) | Reference to the related claim
relationship |  | 0..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference |  | 0..1 | Identifier | File or case reference
prescription |  | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products
originalPrescription |  | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 0..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment Referral
facility | S | 0..1 | Reference(US Core Location Profile(7.0.0)) | Servicing Facility
claim |  | 0..1 | Reference(Claim) | Claim reference
claimResponse |  | 0..1 | Reference(ClaimResponse) | Claim response reference
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..* | string | Preauthorization reference
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period
careTeam |  | 0..* | BackboneElement | Care Team members
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role |  | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification |  | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
supportingInfo |  | 0..* | BackboneElement | Supporting information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Information instance identifier
category |  | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] |  | 1..1 |  | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes.
diagnosisCodeableConcept |  |  | CodeableConcept |
diagnosisReference |  |  | Reference(Condition) |
type |  | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge.
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
precedence |  | 0..1 | positiveInt | Precedence (primary, secondary, etc.)
insurance | Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication
coverage | Σ | 1..1 | Reference(HRex Member Match Coverage Profile(1.1.0)) | Insurance information
preAuthRef |  | 0..* | string | Prior authorization reference number
accident |  | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date |  | 0..1 | date | When the incident occurred
type |  | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc.
location[x] |  | 0..1 |  | Where the event occurred
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
item |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | 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:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
careTeamSequence |  | 0..* | positiveInt | Applicable care team members
diagnosisSequence |  | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence |  | 0..* | positiveInt | Applicable exception and supporting information
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required)
modifier |  | 0..* | CodeableConcept | Product or service billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(US Core Encounter Profile(7.0.0)) | Encounters related to this billed item
noteNumber |  | 0..* | positiveInt | Applicable note numbers
Slices for adjudication |  | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount | S | 1..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | Non-monitary value
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:consumedunits |  | 0..1 | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 1..1 | decimal | Non-monitary value
detail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Additional items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Product or service provided
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity(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
udi |  | 0..* | Reference(Device) | Unique device identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subDetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0)) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place where the service is rendered.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 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
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(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 |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(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 |  | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category
adjudication:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:adjudicationamounttype | 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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes.
amount |  | 1..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
adjudication:denialreason | 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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
extension:adjudicationActionDate | S | 0..1 | dateTime | The date/time when an Adjudication Action occured. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monitary value
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S Σ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible)
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 |  | 0..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 0..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 0..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
benefitPeriod |  | 0..1 | Period | When the benefits are applicable
benefitBalance |  | 0..* | BackboneElement | Balance by Benefit Category
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
excluded |  | 0..1 | boolean | Excluded from the plan
name |  | 0..1 | string | Short name for the benefit
description |  | 0..1 | string | Description of the benefit or services covered
network |  | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services.
unit |  | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family.
term |  | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime.
financial |  | 0..* | BackboneElement | Benefit Summary
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc.
allowed[x] |  | 0..1 |  | Benefits allowed
allowedUnsignedInt |  |  | unsignedInt |
allowedString |  |  | string |
allowedMoney |  |  | Money |
used[x] |  | 0..1 |  | Benefits used
usedUnsignedInt |  |  | unsignedInt |
usedMoney |  |  | Money |
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ExplanationOfBenefit.​meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​status | Base | required | ExplanationOfBenefitStatus | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​use | Base | required | Use | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​priority | Base | required | Process Priority Codes | 📦4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserveRequested | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​related.relationship | Base | example | Example Related Claim Relationship Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payee.type | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.role | Base | example | Claim Care Team Role Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​careTeam.qualification | Base | example | Example Provider Qualification Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.category | Base | example | Claim Information Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.code | Base | example | Exception Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​supportingInfo.reason | Base | example | Missing Tooth Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.diagnosis[x] | Base | example | ICD-10 Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.type | Base | example | Example Diagnosis Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.onAdmission | Base | example | Example Diagnosis on Admission Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​diagnosis.packageCode | Base | example | Example Diagnosis Related Group Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.type | Base | example | Example Procedure Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​procedure.procedure[x] | Base | example | ICD-10 Procedure Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​accident.type | Base | extensible | ActIncidentCode | 📦3.0.0 | THO v6.3
ExplanationOfBenefit.​item.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.category | Base | required | Prior Authorization Service Type Codes (X12) | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.productOrService | Base | required | Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:adjudicationamounttype.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:allowedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:allowedunits.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​item.adjudication:consumedunits.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​revenue | Base | example | Example Revenue Center Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​item.detail.subDetail.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​addItem.detail.subDetail.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication.category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​category | Base | required | PDex Adjudication | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:adjudicationamounttype.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​adjudication:denialreason.​category | Base | required | PDex Adjudication Category Discriminator | 📦2.1.1 | This IG
ExplanationOfBenefit.​adjudication:denialreason.​reason | Base | required | X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes | 📦2.1.1 | This IG
ExplanationOfBenefit.​total.category | Base | extensible | Prior Authorization value categories | 📦2.1.1 | This IG
ExplanationOfBenefit.​payment.type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​payment.adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​processNote.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.category | Base | example | Benefit Category Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.network | Base | example | Network Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.unit | Base | example | Unit Type Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.term | Base | example | Benefit Term Codes | 📍4.0.1 | FHIR Std.
ExplanationOfBenefit.​benefitBalance.financial.​type | Base | example | Benefit Type Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice | `(adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists())`
dom-2 | error | ExplanationOfBenefit | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ExplanationOfBenefit | 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 | ExplanationOfBenefit | 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 | ExplanationOfBenefit | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ExplanationOfBenefit | 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()`

This structure is derived from ExplanationOfBenefit

Summary

Mandatory: 0 element(8 nested mandatory elements)
Must-Support: 36 elements

Structures

This structure refers to these other structures:

- US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
- US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
- US Core PractitionerRole Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole)
- US Core Organization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization)
- US Core Location Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-location)
- HRex Member Match Coverage Profile (http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage)
- US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-levelOfServiceCode
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/base-ext-when-adjudicated
- http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of ExplanationOfBenefit.meta.profile
- The element 1 is sliced based on the value of ExplanationOfBenefit.item.adjudication (Closed)
- The element 1 is sliced based on the value of ExplanationOfBenefit.adjudication (Closed)

Other representations of profile: CSV, Excel, Schematron

### Notes:

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