Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2 United States of America flag

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Resource Profile: PAS Claim Update

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update Version: 2.0.1
Standards status: Trial-use Maturity Level: 3 Computable Name: PASClaimUpdate

PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request

Usage:

Formal Views of Profile Content

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

This structure is derived from PASClaim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... supportingInfo 0..*BackboneElementSupporting information
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag 0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
... item
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag 0..1InfoCancelledFlagIndicates that this piece of information is not to be used.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pas/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.


... conditionCode 0..*(Complex)Used to indicate condition codes for various requests for service.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
... encounter S0..1Reference(Encounter)Information about a hospital claim being requested.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
.... value[x] 1..1Reference(PAS Encounter)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1PASIdentifierBusiness identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... Slices for careTeam S0..*BackboneElementMembers of the care team
Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
.... careTeam:All Slices Content/Rules for all slices
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntOrder of care team
..... provider S1..1Reference(PAS Organization Base Profile | PAS PractitionerRole)Practitioner or organization
..... role S0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

..... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

.... careTeam:OverallClaimMember 0..*BackboneElementCare Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... careTeam:ItemClaimMember 0..*BackboneElementCare Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
.... supportingInfo:PatientEvent 0..1BackboneElementInformation about the dates of the event that are being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:AdmissionDates 0..1BackboneElementInformation about the admission dates of a hospital admission being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionDates
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:DischargeDates 0..1BackboneElementInformation about the discharge dates of a hospital admission being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dischargeDates
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:AdditionalInformation S0..*BackboneElementSend additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalInformation
..... value[x] S1..1Reference(US Core DocumentReference Profile | Resource)Data to be provided
.... supportingInfo:MessageText S0..*BackboneElementSend text messages to the UMO.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: freeFormMessage
..... value[x] S1..1stringData to be provided
... diagnosis S0..*BackboneElementPertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
.... recordedDate S0..1dateThe date that a diagnosis was recorded. (HIxx-4)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
... insurance SΣ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... coverage SΣ1..1Reference(PAS Coverage)Insurance information
... accident S0..1BackboneElementDetails of the event
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... item S1..*BackboneElementProduct or service provided
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... authorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestType S0..1CodeableConceptA code that identifies the type of service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... certificationType S0..1CodeableConceptA code representing the type of certification being requested (UM02)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... productOrServiceCodeEnd 0..1CodeableConceptUsed to provide the last code in a series of codes for the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... epsdtIndicator S0..1booleanAn indicator of whether early and periodic screen for diagnosis and treatment of children is involved.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... nursingHomeResidentialStatus S0..1CodeableConceptA code specifying the status of a nursing home resident at the time of service. (SV209)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... extension 0..0
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
.... nursingHomeLevelOfCare S0..1CodeableConceptA code specifying the level of care provided by a nursing home facility. (SV120, SV210)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... revenueUnitRateLimit S0..1decimalThe limit on the rate per unit of revenue for hospital accomodation. (SV206)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... requestedService S0..1Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)The details of the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category S1..1CodeableConceptSince PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Modifier Type (required)
.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.statusrequiredPattern: active
Claim.typeextensibleClaimTypeCodes
Claim.userequiredPattern: preauthorization
Claim.priorityexampleProcessPriorityCodes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryextensiblePASSupportingInfoType
Claim.supportingInfo:PatientEvent.categoryexamplePattern: patientEvent
Claim.supportingInfo:AdmissionDates.categoryexamplePattern: admissionDates
Claim.supportingInfo:DischargeDates.categoryexamplePattern: dischargeDates
Claim.supportingInfo:AdditionalInformation.categoryextensiblePattern: additionalInformation
Claim.supportingInfo:MessageText.categoryextensiblePattern: freeFormMessage
Claim.diagnosis.diagnosis[x]requiredX12278DiagnosisCodes
Claim.diagnosis.typerequiredX12278DiagnosisType
Claim.accident.typerequiredhttps://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenuerequiredAHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.categoryrequiredhttps://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrServicerequiredX12278RequestedServiceType
Claim.item.modifierrequiredX12278RequestedServiceModifierType
Claim.item.location[x]requiredX12278LocationType
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pas/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.


... conditionCode 0..*(Complex)Used to indicate condition codes for various requests for service.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
... homeHealthCareInformation 0..1(Complex)Used to provide required information about home health care services. (CR6)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
... encounter S0..1Reference(Encounter)Information about a hospital claim being requested.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
.... value[x] 1..1Reference(PAS Encounter)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1PASIdentifierBusiness identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

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

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

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

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

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

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... Slices for careTeam S0..*BackboneElementMembers of the care team
Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
.... careTeam:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntOrder of care team
..... provider S1..1Reference(PAS Organization Base Profile | PAS PractitionerRole)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role S0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

..... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

.... careTeam:OverallClaimMember 0..*BackboneElementCare Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
...... value[x] 0..1booleanValue of extension
Fixed Value: true
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role 0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

..... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
.... careTeam:ItemClaimMember 0..*BackboneElementCare Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
...... value[x] 0..1booleanValue of extension
Fixed Value: false
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role 0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

..... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

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

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionDates
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dischargeDates
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:AdditionalInformation S0..*BackboneElementSend additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalInformation
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... value[x] S1..1Reference(US Core DocumentReference Profile | Resource)Data to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:MessageText S0..*BackboneElementSend text messages to the UMO.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: freeFormMessage
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... value[x] S1..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S0..*BackboneElementPertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... recordedDate S0..1dateThe date that a diagnosis was recorded. (HIxx-4)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

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

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


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

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance SΣ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage SΣ1..1Reference(PAS Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident S0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... authorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestType S0..1CodeableConceptA code that identifies the type of service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... certificationType S0..1CodeableConceptA code representing the type of certification being requested (UM02)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... productOrServiceCodeEnd 0..1CodeableConceptUsed to provide the last code in a series of codes for the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... epsdtIndicator S0..1booleanAn indicator of whether early and periodic screen for diagnosis and treatment of children is involved.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... nursingHomeResidentialStatus S0..1CodeableConceptA code specifying the status of a nursing home resident at the time of service. (SV209)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..0
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
..... value[x] 0..1CodeableConceptValue of extension
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... nursingHomeLevelOfCare S0..1CodeableConceptA code specifying the level of care provided by a nursing home facility. (SV120, SV210)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... revenueUnitRateLimit S0..1decimalThe limit on the rate per unit of revenue for hospital accomodation. (SV206)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... requestedService S0..1Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)The details of the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category S1..1CodeableConceptSince PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Modifier Type (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

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

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


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


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

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

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

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


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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredPattern: active
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredPattern: preauthorization
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.rolerequiredhttps://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualificationrequiredhttps://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.rolerequiredhttps://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualificationrequiredhttps://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.categoryextensiblePASSupportingInfoType
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:PatientEvent.categoryexamplePattern: patientEvent
Claim.supportingInfo:PatientEvent.codeexampleExceptionCodes
Claim.supportingInfo:PatientEvent.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:AdmissionDates.categoryexamplePattern: admissionDates
Claim.supportingInfo:AdmissionDates.codeexampleExceptionCodes
Claim.supportingInfo:AdmissionDates.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:DischargeDates.categoryexamplePattern: dischargeDates
Claim.supportingInfo:DischargeDates.codeexampleExceptionCodes
Claim.supportingInfo:DischargeDates.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:AdditionalInformation.categoryextensiblePattern: additionalInformation
Claim.supportingInfo:AdditionalInformation.codeexampleExceptionCodes
Claim.supportingInfo:AdditionalInformation.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:MessageText.categoryextensiblePattern: freeFormMessage
Claim.supportingInfo:MessageText.codeexampleExceptionCodes
Claim.supportingInfo:MessageText.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]requiredX12278DiagnosisCodes
Claim.diagnosis.typerequiredX12278DiagnosisType
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typerequiredhttps://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.extension:nursingHomeResidentialStatus.value[x]requiredhttps://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345
Claim.item.revenuerequiredAHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.categoryrequiredhttps://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrServicerequiredX12278RequestedServiceType
Claim.item.modifierrequiredX12278RequestedServiceModifierType
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]requiredX12278LocationType
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

Differential View

This structure is derived from PASClaim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... supportingInfo 0..*BackboneElementSupporting information
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag 0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
... item
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag 0..1InfoCancelledFlagIndicates that this piece of information is not to be used.

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pas/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.


... conditionCode 0..*(Complex)Used to indicate condition codes for various requests for service.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
... encounter S0..1Reference(Encounter)Information about a hospital claim being requested.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
.... value[x] 1..1Reference(PAS Encounter)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1PASIdentifierBusiness identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created Σ1..1dateTimeResource creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... Slices for careTeam S0..*BackboneElementMembers of the care team
Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
.... careTeam:All Slices Content/Rules for all slices
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntOrder of care team
..... provider S1..1Reference(PAS Organization Base Profile | PAS PractitionerRole)Practitioner or organization
..... role S0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

..... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

.... careTeam:OverallClaimMember 0..*BackboneElementCare Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
.... careTeam:ItemClaimMember 0..*BackboneElementCare Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
.... supportingInfo:PatientEvent 0..1BackboneElementInformation about the dates of the event that are being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:AdmissionDates 0..1BackboneElementInformation about the admission dates of a hospital admission being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionDates
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:DischargeDates 0..1BackboneElementInformation about the discharge dates of a hospital admission being requested.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dischargeDates
..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
.... supportingInfo:AdditionalInformation S0..*BackboneElementSend additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalInformation
..... value[x] S1..1Reference(US Core DocumentReference Profile | Resource)Data to be provided
.... supportingInfo:MessageText S0..*BackboneElementSend text messages to the UMO.
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: freeFormMessage
..... value[x] S1..1stringData to be provided
... diagnosis S0..*BackboneElementPertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
.... recordedDate S0..1dateThe date that a diagnosis was recorded. (HIxx-4)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
... insurance SΣ1..*BackboneElementPatient insurance information
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... coverage SΣ1..1Reference(PAS Coverage)Insurance information
... accident S0..1BackboneElementDetails of the event
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... item S1..*BackboneElementProduct or service provided
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... authorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestType S0..1CodeableConceptA code that identifies the type of service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... certificationType S0..1CodeableConceptA code representing the type of certification being requested (UM02)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... productOrServiceCodeEnd 0..1CodeableConceptUsed to provide the last code in a series of codes for the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... epsdtIndicator S0..1booleanAn indicator of whether early and periodic screen for diagnosis and treatment of children is involved.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... nursingHomeResidentialStatus S0..1CodeableConceptA code specifying the status of a nursing home resident at the time of service. (SV209)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... extension 0..0
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
.... nursingHomeLevelOfCare S0..1CodeableConceptA code specifying the level of care provided by a nursing home facility. (SV120, SV210)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... revenueUnitRateLimit S0..1decimalThe limit on the rate per unit of revenue for hospital accomodation. (SV206)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... requestedService S0..1Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)The details of the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category S1..1CodeableConceptSince PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Modifier Type (required)
.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.statusrequiredPattern: active
Claim.typeextensibleClaimTypeCodes
Claim.userequiredPattern: preauthorization
Claim.priorityexampleProcessPriorityCodes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.supportingInfo.categoryextensiblePASSupportingInfoType
Claim.supportingInfo:PatientEvent.categoryexamplePattern: patientEvent
Claim.supportingInfo:AdmissionDates.categoryexamplePattern: admissionDates
Claim.supportingInfo:DischargeDates.categoryexamplePattern: dischargeDates
Claim.supportingInfo:AdditionalInformation.categoryextensiblePattern: additionalInformation
Claim.supportingInfo:MessageText.categoryextensiblePattern: freeFormMessage
Claim.diagnosis.diagnosis[x]requiredX12278DiagnosisCodes
Claim.diagnosis.typerequiredX12278DiagnosisType
Claim.accident.typerequiredhttps://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenuerequiredAHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.categoryrequiredhttps://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrServicerequiredX12278RequestedServiceType
Claim.item.modifierrequiredX12278RequestedServiceModifierType
Claim.item.location[x]requiredX12278LocationType

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... levelOfServiceType S0..1CodeableConceptA code specifying the level of service being requested (UM06)
URL: http://hl7.org/fhir/us/davinci-pas/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.


... conditionCode 0..*(Complex)Used to indicate condition codes for various requests for service.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
... homeHealthCareInformation 0..1(Complex)Used to provide required information about home health care services. (CR6)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
... encounter S0..1Reference(Encounter)Information about a hospital claim being requested.
URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
.... value[x] 1..1Reference(PAS Encounter)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1PASIdentifierBusiness identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

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

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Required Pattern: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ1..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

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

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

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

.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment referral
... facility 0..1Reference(Location)Servicing facility
... Slices for careTeam S0..*BackboneElementMembers of the care team
Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
.... careTeam:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntOrder of care team
..... provider S1..1Reference(PAS Organization Base Profile | PAS PractitionerRole)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role S0..1CodeableConceptFunction within the team
Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.

..... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.

.... careTeam:OverallClaimMember 0..*BackboneElementCare Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
...... value[x] 0..1booleanValue of extension
Fixed Value: true
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role 0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

..... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
.... careTeam:ItemClaimMember 0..*BackboneElementCare Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
..... careTeamClaimScope S1..1booleanExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..0
...... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
...... value[x] 0..1booleanValue of extension
Fixed Value: false
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntOrder of care team
..... provider 1..1Reference(Practitioner | PractitionerRole | Organization)Practitioner or organization
..... responsible 0..1booleanIndicator of the lead practitioner
..... role 0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

..... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... Slices for supportingInfo S0..*BackboneElementSupporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

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

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionDates
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

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


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: dischargeDates
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... Slices for timing[x] S1..1When it occurred
Slice: Unordered, Closed by type:$this
...... timingDatedate
...... timingPeriodPeriod
...... timing[x]:timingDate C0..1dateWhen it occurred
...... timing[x]:timingPeriod 0..1PeriodWhen it occurred
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... start ΣC0..1dateTimeStarting time with inclusive boundary
....... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:AdditionalInformation S0..*BackboneElementSend additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: additionalInformation
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... value[x] S1..1Reference(US Core DocumentReference Profile | Resource)Data to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:MessageText S0..*BackboneElementSend text messages to the UMO.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: freeFormMessage
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... value[x] S1..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S0..*BackboneElementPertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... recordedDate S0..1dateThe date that a diagnosis was recorded. (HIxx-4)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

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

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


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

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance SΣ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Required Pattern: true
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage SΣ1..1Reference(PAS Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident S0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... authorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestType S0..1CodeableConceptA code that identifies the type of service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... certificationType S0..1CodeableConceptA code representing the type of certification being requested (UM02)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... productOrServiceCodeEnd 0..1CodeableConceptUsed to provide the last code in a series of codes for the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... epsdtIndicator S0..1booleanAn indicator of whether early and periodic screen for diagnosis and treatment of children is involved.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... nursingHomeResidentialStatus S0..1CodeableConceptA code specifying the status of a nursing home resident at the time of service. (SV209)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..0
..... url 1..1uri"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
..... value[x] 0..1CodeableConceptValue of extension
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... nursingHomeLevelOfCare S0..1CodeableConceptA code specifying the level of care provided by a nursing home facility. (SV120, SV210)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... revenueUnitRateLimit S0..1decimalThe limit on the rate per unit of revenue for hospital accomodation. (SV206)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... requestedService S0..1Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)The details of the service being requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
.... infoChanged 0..1codeA code indicating how the piece of information has changed.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... Slices for modifierExtension ?!Σ0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagIndicates that this piece of information is not to be used.
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category S1..1CodeableConceptSince PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Modifier Type (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

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


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

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

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

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


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


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

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

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

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


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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
... total 0..1MoneyTotal claim cost

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Claim.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Claim.statusrequiredPattern: active
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredPattern: preauthorization
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.roleexampleClaimCareTeamRoleCodes
Claim.careTeam.qualificationexampleExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.rolerequiredhttps://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualificationrequiredhttps://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.rolerequiredhttps://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualificationrequiredhttps://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.categoryextensiblePASSupportingInfoType
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:PatientEvent.categoryexamplePattern: patientEvent
Claim.supportingInfo:PatientEvent.codeexampleExceptionCodes
Claim.supportingInfo:PatientEvent.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:AdmissionDates.categoryexamplePattern: admissionDates
Claim.supportingInfo:AdmissionDates.codeexampleExceptionCodes
Claim.supportingInfo:AdmissionDates.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:DischargeDates.categoryexamplePattern: dischargeDates
Claim.supportingInfo:DischargeDates.codeexampleExceptionCodes
Claim.supportingInfo:DischargeDates.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:AdditionalInformation.categoryextensiblePattern: additionalInformation
Claim.supportingInfo:AdditionalInformation.codeexampleExceptionCodes
Claim.supportingInfo:AdditionalInformation.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:MessageText.categoryextensiblePattern: freeFormMessage
Claim.supportingInfo:MessageText.codeexampleExceptionCodes
Claim.supportingInfo:MessageText.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]requiredX12278DiagnosisCodes
Claim.diagnosis.typerequiredX12278DiagnosisType
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typerequiredhttps://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.extension:nursingHomeResidentialStatus.value[x]requiredhttps://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345
Claim.item.revenuerequiredAHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.categoryrequiredhttps://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrServicerequiredX12278RequestedServiceType
Claim.item.modifierrequiredX12278RequestedServiceModifierType
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]requiredX12278LocationType
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes

 

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