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 Response Base ( Abstract )

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

PAS constraints on ClaimResponse resource that are common to both the request and the inquiry.

Usage:

Formal Views of Profile Content

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

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... identifier S0..*PASIdentifierAn identifier intended for computation
... status S1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: preauthorization
... created S1..1dateTimeResponse creation date
... insurer S1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request S0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome S1..1codequeued | complete | error | partial
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... item S0..*BackboneElementAdjudication for claim line items
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... adjudication S1..*BackboneElementAdjudication details
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... category 1..1CodeableConceptThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
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://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
... error S0..*BackboneElementProcessing errors
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe FHIRPath expression that indicates which FHIR element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*PASIdentifierAn identifier intended for computation
... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Required Pattern: preauthorization
... patient SΣ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request SΣ0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... item S0..*BackboneElementAdjudication for claim line items
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... adjudication S1..*BackboneElementAdjudication details
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptThis 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
... error S0..*BackboneElementProcessing errors
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClaimResponse.statusrequiredPattern: active
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.userequiredPattern: preauthorization
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... 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
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*PASIdentifierAn identifier intended for computation
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptMore granular claim type
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): Claim, preauthorization, predetermination.


Required Pattern: preauthorization
... patient SΣ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request SΣ0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item S0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptThis 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
...... 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://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


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


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

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

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


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

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


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

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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... 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
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*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 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error S0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredPattern: active
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredPattern: preauthorization
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)

This structure is derived from ClaimResponse

Summary

Must-Support: 25 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 3

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... identifier S0..*PASIdentifierAn identifier intended for computation
... status S1..1codeactive | cancelled | draft | entered-in-error
Required Pattern: active
... use 1..1codeclaim | preauthorization | predetermination
Required Pattern: preauthorization
... created S1..1dateTimeResponse creation date
... insurer S1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request S0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome S1..1codequeued | complete | error | partial
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... item S0..*BackboneElementAdjudication for claim line items
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... adjudication S1..*BackboneElementAdjudication details
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... category 1..1CodeableConceptThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
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://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
... error S0..*BackboneElementProcessing errors
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe FHIRPath expression that indicates which FHIR element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*PASIdentifierAn identifier intended for computation
... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Required Pattern: preauthorization
... patient SΣ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request SΣ0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... item S0..*BackboneElementAdjudication for claim line items
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... adjudication S1..*BackboneElementAdjudication details
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptThis 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
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
... error S0..*BackboneElementProcessing errors
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClaimResponse.statusrequiredPattern: active
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.userequiredPattern: preauthorization
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseThis is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse
Response to a claim predetermination or preauthorization
... 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
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*PASIdentifierAn identifier intended for computation
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Required Pattern: active
... type Σ1..1CodeableConceptMore granular claim type
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): Claim, preauthorization, predetermination.


Required Pattern: preauthorization
... patient SΣ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(PAS Insurer Organization)Party responsible for reimbursement
... requestor S0..1Reference(PAS Requestor Organization | PAS PractitionerRole)Party responsible for the claim
... request SΣ0..1Reference(PAS Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item S0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... itemTraceNumber S0..*PASIdentifierUniquely identifies this claim item. (2000F-TRN)
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... preAuthIssueDate S0..1dateThe date when this item's preauthorization was issued.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... preAuthPeriod S0..1PeriodThe date/period when this item's preauthorization is valid.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... previousAuthorizationNumber S0..1stringA string assigned by the UMO to an authorized review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... administrationReferenceNumber S0..1stringA string assigned by the UMO to the original disallowed review outcome associated with this service item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... requestedServiceDate S0..1dateTime, PeriodThe original date/period that was requested by the submitter for this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
.... authorizedItemDetail S0..1(Complex)The details of what has been authorized for this item if different from what was requested.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
.... authorizedProvider S0..*(Complex)The specific provider who has been authorized to provide this item.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
..... reviewAction S0..1(Complex)The details of the review action that is necessary for the authorization.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptThis 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
...... 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://terminology.hl7.org/CodeSystem/adjudication
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: submitted
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

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


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


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

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

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


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

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


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

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


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... 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
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*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 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error S0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... followupAction S0..1CodeableConceptA 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 S0..1stringThe specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
.... errorPath S0..1stringThe 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 ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code S1..1CodeableConceptError code detailing processing issues
Binding: X12 278 Reject Reason Value Set (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredPattern: active
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredPattern: preauthorization
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.coderequiredX12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901)

This structure is derived from ClaimResponse

Summary

Must-Support: 25 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron