Intersection of http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update and http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update

This is the set of resources that conform to both PAS Claim Update (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update) and PAS Claim Update (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update).

Structure

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Claim		0..*		Preauthorization
Claim.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
Claim.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
Claim.language		0..1	code	Language of the resource content Binding: ?? (preferred): A human language. Additional Bindings Purpose ?? Max Binding
Claim.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Claim.contained		0..*	Resource	Contained, inline Resources
Claim.extension		0..*	Extension	Extension
Claim.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
Claim.identifier	S This element must be supported.	1..2	?? , ??	Business identifier for claim
Claim.identifier.extension		0..*	Extension	Additional content defined by implementations
Claim.identifier.use	?! This element is a modifier element. Σ This element is included in summaries.	0..1	code	usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known .
Claim.identifier.type	Σ This element is included in summaries.	0..1	CodeableConcept	Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Claim.identifier.system	S This element must be supported. Σ This element is included in summaries.	1..1	uri	SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
Claim.identifier.value	S This element must be supported. Σ This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
Claim.identifier.period	Σ This element is included in summaries.	0..1	Period	Time period when id is/was valid for use
Claim.identifier.assigner	Σ This element is included in summaries.	0..1	Reference(Organization)	Organization that issued id (may be just text)
Claim.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	left: active | cancelled | draft | entered-in-error; right: This is fixed to active even if the CertificationType is indicating that the Claim is to be cancelled as it reflects that status of this instance and not the overall Claim Binding: ?? (required): A code specifying the state of the resource instance.
Claim.type	Σ This element is included in summaries.	1..1	CodeableConcept	left: Category or discipline; right: This is used as a high-level mapping of the X12 UM03 field Binding: ?? (required): The type or discipline-style of the claim.
Claim.subType		0..1	CodeableConcept	More granular claim type Binding: ?? (example): A more granular claim typecode.
Claim.use	S This element must be supported. Σ This element is included in summaries.	1..1	code	claim | preauthorization | predetermination Binding: ?? (required): The purpose of the Claim: predetermination, preauthorization, claim.
Claim.patient	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient | #sd-49-profile-beneficiary-profile-beneficiary)	The recipient of the products and services
Claim.billablePeriod	Σ This element is included in summaries.	0..1	Period	Relevant time frame for the claim
Claim.created	Σ This element is included in summaries.	1..1	dateTime	Resource creation date
Claim.enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
Claim.insurer	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Insurer Organization | #sd-69-profile-insurer-profile-insurer)	Target
Claim.provider	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole | #sd-70-profile-requestor-profile-requestor)	Party responsible for the claim
Claim.priority	Σ This element is included in summaries.	1..1	CodeableConcept	Desired processing ugency Binding: ?? (example): The timeliness with which processing is required: stat, normal, deferred.
Claim.fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
Claim.related	S This element must be supported.	1..1	BackboneElement	Prior or corollary claims
Claim.related.extension		0..*	Extension	Additional content defined by implementations
Claim.related.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.related.claim	S This element must be supported.	1..1	Reference(Claim)	Reference to the related claim
Claim.related.relationship	S This element must be supported.	1..1	CodeableConcept	How the reference claim is related Binding: ?? (example): Relationship of this claim to a related Claim.
Claim.related.reference		0..1	Identifier	File or case reference
Claim.prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
Claim.originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
Claim.payee		0..1	BackboneElement	Recipient of benefits payable
Claim.payee.extension		0..*	Extension	Additional content defined by implementations
Claim.payee.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.payee.type		1..1	CodeableConcept	Category of recipient Binding: ?? (example): A code for the party to be reimbursed.
Claim.payee.party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
Claim.referral		0..1	Reference(ServiceRequest)	Treatment referral
Claim.facility		0..1	Reference(Location)	Servicing facility
Claim.careTeam	S This element must be supported.	0..*	BackboneElement	Members of the care team
Claim.careTeam.extension		1..*	Extension	Extension
Claim.careTeam.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.careTeam.sequence	S This element must be supported.	1..1	positiveInt	Order of care team
Claim.careTeam.provider	S This element must be supported.	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole | #sd-75-profile-organization-profile-organization)	Practitioner or organization
Claim.careTeam.responsible		0..1	boolean	Indicator of the lead practitioner
Claim.careTeam.role	S This element must be supported.	0..1	CodeableConcept	Function within the team Binding: ?? (example): The role codes for the care team members.
Claim.careTeam.qualification	S This element must be supported.	0..1	CodeableConcept	Practitioner credential or specialization Binding: ?? (example): Provider professional qualifications.
Claim.supportingInfo	S This element must be supported.	0..*	BackboneElement	Supporting information
Claim.supportingInfo.extension		0..*	Extension	Extension
Claim.supportingInfo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extension
Claim.supportingInfo.sequence	S This element must be supported.	1..1	positiveInt	Information instance identifier
Claim.supportingInfo.category	S This element must be supported.	1..1	CodeableConcept	Classification of the supplied information Binding: ?? (extensible)
Claim.supportingInfo.code		0..1	CodeableConcept	Type of information Binding: ?? (example): The valuset used for additional information codes.
Claim.supportingInfo.timing[x]		0..1		When it occurred
Claim.supportingInfo.timing[x].timingDate			date
Claim.supportingInfo.timing[x].timingPeriod			Period
Claim.supportingInfo.value[x]		0..1		Data to be provided
Claim.supportingInfo.value[x].valueBoolean			boolean
Claim.supportingInfo.value[x].valueString			string
Claim.supportingInfo.value[x].valueQuantity			Quantity
Claim.supportingInfo.value[x].valueAttachment			Attachment
Claim.supportingInfo.value[x].valueReference			Reference(Resource)
Claim.supportingInfo.reason		0..1	CodeableConcept	Explanation for the information Binding: ?? (example): Reason codes for the missing teeth.
Claim.diagnosis	S This element must be supported.	0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Claim.diagnosis.extension		0..*	Extension	Extension
Claim.diagnosis.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.diagnosis.sequence	S This element must be supported.	1..1	positiveInt	Diagnosis instance identifier
Claim.diagnosis.diagnosis[x]	S This element must be supported.	1..1	CodeableConcept	Nature of illness or problem Binding: ?? (required)
Claim.diagnosis.type	S This element must be supported.	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: ?? (required)
Claim.diagnosis.onAdmission		0..1	CodeableConcept	Present on admission Binding: ?? (example): Present on admission.
Claim.diagnosis.packageCode		0..1	CodeableConcept	Package billing code Binding: ?? (example): The DRG codes associated with the diagnosis.
Claim.procedure		0..*	BackboneElement	Clinical procedures performed
Claim.procedure.extension		0..*	Extension	Additional content defined by implementations
Claim.procedure.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.procedure.sequence		1..1	positiveInt	Procedure instance identifier
Claim.procedure.type		0..*	CodeableConcept	Category of Procedure Binding: ?? (example): Example procedure type codes.
Claim.procedure.date		0..1	dateTime	When the procedure was performed
Claim.procedure.procedure[x]		1..1		Specific clinical procedure Binding: ?? (example): Example ICD10 Procedure codes.
Claim.procedure.procedure[x].procedureCodeableConcept			CodeableConcept
Claim.procedure.procedure[x].procedureReference			Reference(Procedure)
Claim.procedure.udi		0..*	Reference(Device)	Unique device identifier
Claim.insurance	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Patient insurance information
Claim.insurance.extension		0..*	Extension	Additional content defined by implementations
Claim.insurance.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.insurance.sequence	S This element must be supported. Σ This element is included in summaries.	1..1	positiveInt	Insurance instance identifier
Claim.insurance.focal	Σ This element is included in summaries.	1..1	boolean	Coverage to be used for adjudication
Claim.insurance.identifier		0..1	Identifier	Pre-assigned Claim number
Claim.insurance.coverage	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(PAS Coverage | #sd-86-profile-coverage-profile-coverage)	Insurance information
Claim.insurance.businessArrangement		0..1	string	Additional provider contract number
Claim.insurance.preAuthRef		0..*	string	Prior authorization reference number
Claim.insurance.claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
Claim.accident	S This element must be supported.	0..1	BackboneElement	Details of the event
Claim.accident.extension		0..*	Extension	Additional content defined by implementations
Claim.accident.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.accident.date	S This element must be supported. C	1..1	date	When the incident occurred Constraints: FullDateRule
Claim.accident.type	S This element must be supported.	0..1	CodeableConcept	The nature of the accident Binding: ?? (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
Claim.accident.location[x]	S This element must be supported.	0..1	Address	Where the event occurred
Claim.item	S This element must be supported. C	1..*	BackboneElement	Product or service provided Constraints: ImmediateLevelOfCare
Claim.item.extension		2..*	Extension	Extension
Claim.item.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extension
Claim.item.sequence	S This element must be supported.	1..1	positiveInt	left: Item instance identifier; right: Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
Claim.item.careTeamSequence	S This element must be supported.	0..*	positiveInt	Applicable careTeam members
Claim.item.diagnosisSequence	S This element must be supported.	0..*	positiveInt	Applicable diagnoses
Claim.item.procedureSequence		0..*	positiveInt	Applicable procedures
Claim.item.informationSequence	S This element must be supported.	0..*	positiveInt	Applicable exception and supporting information
Claim.item.revenue	S This element must be supported.	0..1	CodeableConcept	Revenue or cost center code Binding: ?? (required)
Claim.item.category	S This element must be supported.	1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: ?? (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
Claim.item.productOrService	S This element must be supported.	1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (required)
Claim.item.modifier	S This element must be supported.	0..*	CodeableConcept	Product or service billing modifiers Binding: ?? (required)
Claim.item.programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
Claim.item.serviced[x]	S This element must be supported.	0..1		Date or dates of service or product delivery
Claim.item.serviced[x].servicedDate			date
Claim.item.serviced[x].servicedPeriod			Period
Claim.item.location[x]	S This element must be supported.	1..1	CodeableConcept	Place of service or where product was supplied Binding: ?? (required)
Claim.item.quantity	S This element must be supported. C	0..1	?? , ??	left: A fixed quantity (no comparator); right: Count of products or services Constraints: qty-3, sqty-1
Claim.item.unitPrice	S This element must be supported.	0..1	Money	Fee, charge or cost per item
Claim.item.factor		0..1	decimal	Price scaling factor
Claim.item.net		0..1	Money	Total item cost
Claim.item.udi		0..*	Reference(Device)	Unique device identifier
Claim.item.bodySite		0..1	CodeableConcept	Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.
Claim.item.subSite		0..*	CodeableConcept	Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations.
Claim.item.encounter		0..*	Reference(Encounter)	Encounters related to this billed item
Claim.item.detail		0..*	BackboneElement	Product or service provided
Claim.item.detail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
Claim.item.detail.category		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral-basic, major, glasses.
Claim.item.detail.productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
Claim.item.detail.modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (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.
Claim.item.detail.programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
Claim.item.detail.quantity		0..1	?? , ??	Count of products or services
Claim.item.detail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.net		0..1	Money	Total item cost
Claim.item.detail.udi		0..*	Reference(Device)	Unique device identifier
Claim.item.detail.subDetail		0..*	BackboneElement	Product or service provided
Claim.item.detail.subDetail.extension		0..*	Extension	Additional content defined by implementations
Claim.item.detail.subDetail.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Claim.item.detail.subDetail.sequence		1..1	positiveInt	Item instance identifier
Claim.item.detail.subDetail.revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
Claim.item.detail.subDetail.category		0..1	CodeableConcept	Benefit classification Binding: ?? (example): Benefit categories such as: oral-basic, major, glasses.
Claim.item.detail.subDetail.productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes.
Claim.item.detail.subDetail.modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ?? (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.
Claim.item.detail.subDetail.programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ?? (example): Program specific reason codes.
Claim.item.detail.subDetail.quantity		0..1	?? , ??	Count of products or services
Claim.item.detail.subDetail.unitPrice		0..1	Money	Fee, charge or cost per item
Claim.item.detail.subDetail.factor		0..1	decimal	Price scaling factor
Claim.item.detail.subDetail.net		0..1	Money	Total item cost
Claim.item.detail.subDetail.udi		0..*	Reference(Device)	Unique device identifier
Claim.total		0..1	Money	Total claim cost
Documentation for this format