Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2
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 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse | Version: 2.1.0 | |||
| Standards status: Trial-use | Maturity Level: 3 | Computable Name: PASClaimInquiryResponse | ||
PAS constraints on Claim resource mandating support for elements relevant to the response of an inquiry for details of previous authorizations.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from PASClaimResponseBase
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |
  item |
||||
  Slices for extension |
Content/Rules for all slices | |||
  communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
  identifier |
S | 0..* | PASIdentifier | An identifier intended for computation |
 Slices for extension |
Content/Rules for all slices | |||
 subDepartment |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment |
| jurisdiction |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (required) |
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| system |
SΣ | 1..1 | uri | Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient |
 value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active |
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization |
 patient |
SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created |
SΣ | 1..1 | dateTime | Response creation date |
| insurer |
SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor |
S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request |
SΣ | 1..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| preAuthPeriod |
S | 0..1 | Period | Preauthorization reference effective period |
| item |
S | 0..* | BackboneElement | Adjudication for claim line items |
| Slices for extension |
Content/Rules for all slices | |||
| itemTraceNumber |
S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate |
S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod |
S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber |
S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber |
S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate |
S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail |
S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider |
S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence |
S | 1..1 | positiveInt | Claim item instance identifier |
| adjudication |
S | 1..* | BackboneElement | Adjudication details |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| addItem |
S | 0..* | BackboneElement | Insurer added line items |
| Slices for extension |
Content/Rules for all slices | |||
| itemTraceNumber |
S | 0..* | PASIdentifier | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate |
S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod |
S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| epsdtIndicator |
S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator |
| nursingHomeResidentialStatus |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus |
| nursingHomeLevelOfCare |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. |
| revenueUnitRateLimit |
S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit |
| requestedService |
S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence |
S | 1..1 | positiveInt | Item sequence number |
| provider |
S | 0..* | Reference(PAS Practitioner | PAS Organization Base Profile) | Authorized providers |
| productOrService |
S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required) |
| modifier |
S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required) |
 serviced[x] |
S | 0..1 | Date or dates of service or product delivery | |
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| location[x] |
S | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | |
| locationCodeableConcept |
CodeableConcept | |||
| locationAddress |
Address | |||
| locationReference |
Reference(Location) | |||
| quantity |
SC | 0..1 | PASQuantity | A fixed quantity (no comparator) qty-3: If a code for the unit is present, the system SHALL also be present sqty-1: The comparator is not used on a SimpleQuantity |
| unitPrice |
S | 0..1 | Money | Fee, charge or cost per item |
| adjudication |
S | 1..* | BackboneElement | Added items adjudication |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| adjudication |
S | 0..* | BackboneElement | Header-level adjudication |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error |
S | 0..* | BackboneElement | Processing errors |
| Slices for extension |
Content/Rules for all slices | |||
| followupAction |
S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement |
S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath |
S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Pattern: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrService | required | X12278RequestedServiceTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceTypefrom this IG | |
| ClaimResponse.addItem.modifier | required | X12278RequestedServiceModifierTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierTypefrom this IG | |
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | |
| ClaimResponse.addItem.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodesfrom this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
S | 0..* | PASIdentifier | An identifier intended for computation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| subDepartment |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment | ||||
| jurisdiction |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (required) | ||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system |
SΣ | 1..1 | uri | Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient | ||||
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType |
0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization | ||||
| patient |
SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services | ||||
| created |
SΣ | 1..1 | dateTime | Response creation date | ||||
| insurer |
SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement | ||||
| requestor |
S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim | ||||
| request |
SΣ | 1..1 | Reference(PAS Claim) | Id of resource triggering adjudication | ||||
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
S | 0..1 | Period | Preauthorization reference effective period | ||||
| payeeType |
0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item |
S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber |
S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate |
S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod |
S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber |
S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber |
S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| requestedServiceDate |
S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate | ||||
| authorizedItemDetail |
S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail | ||||
| authorizedProvider |
S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | ||||
| communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
S | 1..1 | positiveInt | Claim item instance identifier | ||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
S | 1..* | BackboneElement | Adjudication details | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Adjudication for claim details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence |
1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence |
1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem |
S | 0..* | BackboneElement | Insurer added line items | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber |
S | 0..* | PASIdentifier | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate |
S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod |
S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| epsdtIndicator |
S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator | ||||
| nursingHomeResidentialStatus |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus | ||||
| nursingHomeLevelOfCare |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. | ||||
| revenueUnitRateLimit |
S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit | ||||
| requestedService |
S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
S | 1..1 | positiveInt | Item sequence number | ||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| provider |
S | 0..* | Reference(PAS Practitioner | PAS Organization Base Profile) | Authorized providers | ||||
| productOrService |
S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required) | ||||
| modifier |
S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required) | ||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
S | 0..1 | Date or dates of service or product delivery | |||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
S | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | |||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
SC | 0..1 | PASQuantity | A fixed quantity (no comparator) qty-3: If a code for the unit is present, the system SHALL also be present sqty-1: The comparator is not used on a SimpleQuantity | ||||
| unitPrice |
S | 0..1 | Money | Fee, charge or cost per item | ||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
S | 1..* | BackboneElement | Added items adjudication | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Insurer added line details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication |
S | 0..* | BackboneElement | Header-level adjudication | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
1..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text |
1..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest |
0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance |
0..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Insurance instance identifier | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(Coverage) | Insurance information | |||||
| businessArrangement |
0..1 | string | Additional provider contract number | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error |
S | 0..* | BackboneElement | Processing errors | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| followupAction |
S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) | ||||
| errorElement |
S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement | ||||
| errorPath |
S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..1 | positiveInt | Item sequence number | |||||
| detailSequence |
0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence |
0..1 | positiveInt | Subdetail sequence number | |||||
| code |
S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| ClaimResponse.use | required | Pattern: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.productOrService | required | X12278RequestedServiceTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceTypefrom this IG | ||||
| ClaimResponse.addItem.modifier | required | X12278RequestedServiceModifierTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierTypefrom this IG | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ClaimResponse.addItem.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.addItem.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodesfrom this IG |
This structure is derived from PASClaimResponseBase
Differential View
This structure is derived from PASClaimResponseBase
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |
| item |
||||
| Slices for extension |
Content/Rules for all slices | |||
| communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
S | 0..* | PASIdentifier | An identifier intended for computation |
| Slices for extension |
Content/Rules for all slices | |||
| subDepartment |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment |
| jurisdiction |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (required) |
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . |
| system |
SΣ | 1..1 | uri | Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient |
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 |
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active |
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization |
| patient |
SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created |
SΣ | 1..1 | dateTime | Response creation date |
| insurer |
SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor |
S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request |
SΣ | 1..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| preAuthPeriod |
S | 0..1 | Period | Preauthorization reference effective period |
| item |
S | 0..* | BackboneElement | Adjudication for claim line items |
| Slices for extension |
Content/Rules for all slices | |||
| itemTraceNumber |
S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate |
S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod |
S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber |
S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber |
S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate |
S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail |
S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider |
S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence |
S | 1..1 | positiveInt | Claim item instance identifier |
| adjudication |
S | 1..* | BackboneElement | Adjudication details |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| addItem |
S | 0..* | BackboneElement | Insurer added line items |
| Slices for extension |
Content/Rules for all slices | |||
| itemTraceNumber |
S | 0..* | PASIdentifier | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate |
S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod |
S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| epsdtIndicator |
S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator |
| nursingHomeResidentialStatus |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus |
| nursingHomeLevelOfCare |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. |
| revenueUnitRateLimit |
S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit |
| requestedService |
S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence |
S | 1..1 | positiveInt | Item sequence number |
| provider |
S | 0..* | Reference(PAS Practitioner | PAS Organization Base Profile) | Authorized providers |
| productOrService |
S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required) |
| modifier |
S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required) |
| serviced[x] |
S | 0..1 | Date or dates of service or product delivery | |
| servicedDate |
date | |||
| servicedPeriod |
Period | |||
| location[x] |
S | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | |
| locationCodeableConcept |
CodeableConcept | |||
| locationAddress |
Address | |||
| locationReference |
Reference(Location) | |||
| quantity |
SC | 0..1 | PASQuantity | A fixed quantity (no comparator) qty-3: If a code for the unit is present, the system SHALL also be present sqty-1: The comparator is not used on a SimpleQuantity |
| unitPrice |
S | 0..1 | Money | Fee, charge or cost per item |
| adjudication |
S | 1..* | BackboneElement | Added items adjudication |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| adjudication |
S | 0..* | BackboneElement | Header-level adjudication |
| Slices for extension |
Content/Rules for all slices | |||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error |
S | 0..* | BackboneElement | Processing errors |
| Slices for extension |
Content/Rules for all slices | |||
| followupAction |
S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement |
S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath |
S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | |
| ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Pattern: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrService | required | X12278RequestedServiceTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceTypefrom this IG | |
| ClaimResponse.addItem.modifier | required | X12278RequestedServiceModifierTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierTypefrom this IG | |
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | |
| ClaimResponse.addItem.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodesfrom this IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse |
0..* | PASClaimResponseBase | Response to a preauthorization query | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
S | 0..* | PASIdentifier | An identifier intended for computation | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| subDepartment |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment | ||||
| jurisdiction |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (required) | ||||
| use |
?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
| type |
Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
| system |
SΣ | 1..1 | uri | Should use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient | ||||
| value |
SΣ | 1..1 | string | The value that is unique Example General: 123456 | ||||
| period |
Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
| assigner |
Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
| status |
?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType |
0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use |
Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization | ||||
| patient |
SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services | ||||
| created |
SΣ | 1..1 | dateTime | Response creation date | ||||
| insurer |
SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement | ||||
| requestor |
S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim | ||||
| request |
SΣ | 1..1 | Reference(PAS Claim) | Id of resource triggering adjudication | ||||
| outcome |
SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
S | 0..1 | Period | Preauthorization reference effective period | ||||
| payeeType |
0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item |
S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber |
S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate |
S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod |
S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber |
S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber |
S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| requestedServiceDate |
S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate | ||||
| authorizedItemDetail |
S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail | ||||
| authorizedProvider |
S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | ||||
| communicatedDiagnosis |
S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
S | 1..1 | positiveInt | Claim item instance identifier | ||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
S | 1..* | BackboneElement | Adjudication details | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Adjudication for claim details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence |
1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence |
1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem |
S | 0..* | BackboneElement | Insurer added line items | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber |
S | 0..* | PASIdentifier | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate |
S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod |
S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber |
S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| epsdtIndicator |
S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator | ||||
| nursingHomeResidentialStatus |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus | ||||
| nursingHomeLevelOfCare |
S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions. | ||||
| revenueUnitRateLimit |
S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit | ||||
| requestedService |
S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
S | 1..1 | positiveInt | Item sequence number | ||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| provider |
S | 0..* | Reference(PAS Practitioner | PAS Organization Base Profile) | Authorized providers | ||||
| productOrService |
S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required) | ||||
| modifier |
S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required) | ||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
S | 0..1 | Date or dates of service or product delivery | |||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
S | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | |||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
SC | 0..1 | PASQuantity | A fixed quantity (no comparator) qty-3: If a code for the unit is present, the system SHALL also be present sqty-1: The comparator is not used on a SimpleQuantity | ||||
| unitPrice |
S | 0..1 | Money | Fee, charge or cost per item | ||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite |
0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
S | 1..* | BackboneElement | Added items adjudication | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Insurer added line details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService |
1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| adjudication |
1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication |
S | 0..* | BackboneElement | Header-level adjudication | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction |
S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| value |
0..1 | decimal | Non-monetary value | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
1..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text |
1..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest |
0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance |
0..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Insurance instance identifier | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(Coverage) | Insurance information | |||||
| businessArrangement |
0..1 | string | Additional provider contract number | |||||
| claimResponse |
0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error |
S | 0..* | BackboneElement | Processing errors | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| followupAction |
S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) | ||||
| errorElement |
S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement | ||||
| errorPath |
S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..1 | positiveInt | Item sequence number | |||||
| detailSequence |
0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence |
0..1 | positiveInt | Subdetail sequence number | |||||
| code |
S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-typefrom the FHIR Standard | ||||
| ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| ClaimResponse.use | required | Pattern: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.productOrService | required | X12278RequestedServiceTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceTypefrom this IG | ||||
| ClaimResponse.addItem.modifier | required | X12278RequestedServiceModifierTypehttp://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierTypefrom this IG | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ClaimResponse.addItem.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.addItem.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodesfrom this IG |
This structure is derived from PASClaimResponseBase
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.1.0 based on FHIR 4.0.1. Generated 2024-11-19
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