PAS Claim Response - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.1

1..1

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

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

0..*

Adjudication for claim details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

detailSequence

1..1

Claim detail instance identifier

0..*

Applicable note numbers

1..*

Detail level adjudication details

0..*

Adjudication for claim sub-details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Claim sub-detail instance identifier

0..*

Applicable note numbers

0..*

Subdetail level adjudication details

addItem

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..*

extension:itemTraceNumber

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

0..*

PASIdentifier(2.2.1)

Item Trace Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber

extension:preAuthIssueDate

0..1

Item Preauthorization Issue Date
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate

extension:preAuthPeriod

0..1

extension:previousAuthorizationNumber

Item Preauthorization Period
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod

0..1

extension:administrationReferenceNumber

Authorization Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber

0..1

Administration Reference Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber

extension:epsdtIndicator

0..1

extension:nursingHomeResidentialStatus

EPSDT Indicator
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator

0..1

extension:nursingHomeLevelOfCare

Nursing Home Residential Status
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus

0..1

extension:productOrServiceCodeEnd

Nursing Home Level of Care
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.

0..1

Product or Service Code End
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12278RequestedServiceType (2.2.1) (required)

extension:revenue

0..1

extension:revenueUnitRateLimit

Revenue Code
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode
Binding: AHANUBCRevenueCodes (2.2.1) (required)

0..1

extension:requestedService

Revenue Unit Rate Limit
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit

0..1

Reference(PAS Medication Request(2.2.1) | PAS Service Request(2.2.1) | PAS Device Request(2.2.1) | PAS Nutrition Order(2.2.1))

Requested Service
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

extension:requestType

0..1

extension:certificationType

Service Item Request Type
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

0..1

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

extension:category

0..1

Claim Response Item Category
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

extension:admissionDates

0..1

Admission Dates
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates

extension:dischargeDate

0..1

Discharge Date
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Item sequence number

0..*

Detail sequence number

subdetailSequence

0..*

Reference(PAS Practitioner(2.2.1) | PAS Organization Base Profile(2.2.1))

Subdetail sequence number

provider

0..*

Authorized providers

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

extension:providerType

0..1

Authorized Provider Type
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType
Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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.

reference

0..1

Literal reference, Relative, internal or absolute URL

0..1

Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

0..1

Logical reference, when literal reference is not known

0..1

Text alternative for the resource

1..1

Billing, service, product, or drug code
Binding: X12278RequestedServiceType (2.2.1) (required)

0..*

Service/Product billing modifiers
Binding: X12278RequestedServiceModifierType (2.2.1) (required)

programCode

0..*

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

serviced[x]

0..1

Date or dates of service or product delivery

servicedDate

servicedPeriod

location[x]

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

locationCodeableConcept

locationAddress

locationReference

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

bodySite

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

subSite

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

0..*

Applicable note numbers

1..*

Added items adjudication

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

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

0..*

Extensions that cannot be ignored even if unrecognized

1..1

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

0..*

Insurer added line details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..*

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.

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

0..*

Applicable note numbers

1..*

Added items detail adjudication

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..*

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

0..*

Applicable note numbers

1..*

Added items detail adjudication

0..*

Header-level adjudication

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

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

0..*

Extensions that cannot be ignored even if unrecognized

1..1

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

total

0..*

Adjudication totals

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

1..1

Financial total for the category

payment

0..1

Payment Details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

adjustment

0..1

Payment adjustment for non-claim issues

adjustmentReason

0..1

Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

0..1

Expected date of payment

1..1

Payable amount after adjustment

0..1

Business identifier for the payment

fundsReserve

0..1

Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

formCode

0..1

Printed form identifier
Binding: Form Codes (example): The forms codes.

form

0..1

Attachment

Printed reference or actual form

processNote

0..*

Note concerning adjudication

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

number

1..1

Note instance identifier

0..1

display | print | printoper
Binding: NoteType (required): The presentation types of notes.

1..1

Note explanatory text

language

0..1

Reference(PAS CommunicationRequest(2.2.1))

Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

AllLanguages

Max Binding

communicationRequest

0..*

Request for additional information

insurance

0..*

Patient insurance information

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Insurance instance identifier

focal

1..1

Coverage to be used for adjudication

coverage

1..1

Reference(Coverage)

Insurance information

businessArrangement

0..1

Additional provider contract number

claimResponse

0..1

Reference(ClaimResponse)

Adjudication results

error

0..*

Processing errors

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

extension:followupAction

0..1

A code representing what action must occur to resolve this error.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction
Binding: X12278FollowUpActionCodes (2.2.1) (required)

extension:errorElement

0..1

(Complex)

The specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement

extension:errorPath

0..1

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

0..*

Extensions that cannot be ignored even if unrecognized

0..1

Item sequence number

0..1

Detail sequence number

0..1

Subdetail sequence number

1..1

Documentation for this format

Error code detailing processing issues
Binding: X12278RejectReasonCodes (2.2.1) (required)

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.identifier.use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier.type	Base	extensible	IdentifierType	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.subType	Base	example	Example Claim SubType Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.request.type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.1	This IG
ClaimResponse.payeeType	Base	example	PayeeType	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.item.adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.provider.type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
ClaimResponse.addItem.productOrService	Base	required	X12 278 Requested Service Type	📍2.2.1	This IG
ClaimResponse.addItem.modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.1	This IG
ClaimResponse.addItem.programCode	Base	example	Example Program Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.bodySite	Base	example	Oral Site Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.subSite	Base	example	Surface Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.detail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.detail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.detail.subDetail.productOrService	Base	example	USCLS Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.detail.subDetail.modifier	Base	example	Modifier type Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.reason	Base	example	Adjudication Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.total.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.type	Base	example	Example Payment Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.payment.adjustmentReason	Base	example	Payment Adjustment Reason Codes	📍4.0.1	FHIR Std.
ClaimResponse.fundsReserve	Base	example	FundsReserve	📍4.0.1	FHIR Std.
ClaimResponse.formCode	Base	example	Forms	📍4.0.1	FHIR Std.
ClaimResponse.processNote.type	Base	required	NoteType	📍4.0.1	FHIR Std.
ClaimResponse.processNote.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.error.code	Base	required	X12 278 Reject Reason Value Set	📍2.2.1	This IG

Constraints

Grade

Path(s)

Description

Expression

This structure is derived from PASClaimResponseBase

Summary

Must-Support: 2 elements

Structures

This structure refers to these other structures:

PAS CommunicationRequest (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-communicationrequest|2.2.1)

Extensions

This structure refers to these extensions:

http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis|2.2.1

Maturity: 4

Key Elements View

Name	Flags	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
ClaimResponse		0..*	PASClaimResponseBase(2.2.1)	Response to a preauthorization
ClaimResponse.implicitRules	This element is a modifier element. This element is included in summaries.	0..1	uri	A set of rules under which this content was created
ClaimResponse.Slices for extension				Content/Rules for all slices
ClaimResponse.Slices for extension.extension:transmissionIdentifiers	This element must be supported.	0..1	(Complex)	Transmission Identifiers URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-TransmissionIdentifiers
ClaimResponse.Slices for extension.extension:claimResponseReviewer	This element must be supported.	0..1	(Complex)	The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
ClaimResponse.Slices for extension.extension:authorizedProvider	This element must be supported.	0..*	(Complex)	Item Authorized Provider URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
ClaimResponse.modifierExtension	This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
ClaimResponse.identifier	This element must be supported.	0..*	PASIdentifier(2.2.1)	Business Identifier for a claim response
ClaimResponse.identifier.Slices for extension				Content/Rules for all slices
ClaimResponse.identifier.Slices for extension.extension:subDepartment	This element must be supported.	0..1	string	Identifier Sub-Department URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
ClaimResponse.identifier.Slices for extension.extension:jurisdiction	This element must be supported.	0..1	CodeableConcept	Identifier Jurisdiction URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
ClaimResponse.identifier.use	This element is a modifier element. This element is included in summaries.	0..1	code	usual \| official \| temp \| secondary \| old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
ClaimResponse.identifier.system	This element must be supported. 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
ClaimResponse.identifier.value	This element must be supported. This element is included in summaries.	1..1	string	The value that is unique Example General: 123456
ClaimResponse.status	This element is a modifier element. This element must be supported. This element is included in summaries.	1..1	code	active \| cancelled \| draft \| entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
ClaimResponse.type	This element is included in summaries.	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
ClaimResponse.use	This element is included in summaries.	1..1	code	claim \| preauthorization \| predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
ClaimResponse.patient	This element must be supported. This element is included in summaries.	1..1	Reference(PAS Beneficiary Patient(2.2.1))	The recipient of the products and services
ClaimResponse.created	This element must be supported. This element is included in summaries.	1..1	dateTime	Response creation date
ClaimResponse.insurer	This element must be supported. This element is included in summaries.	1..1	Reference(PAS Insurer Organization(2.2.1))	Party responsible for reimbursement
ClaimResponse.requestor	This element must be supported.	0..1	Reference(PAS Requestor Organization(2.2.1) \| PAS PractitionerRole(2.2.1))	Party responsible for the claim
ClaimResponse.request	This element must be supported. This element is included in summaries.	1..1	Reference(PAS Claim(2.2.1))	Id of resource triggering adjudication
ClaimResponse.request.Slices for extension				Content/Rules for all slices
ClaimResponse.request.Slices for extension.extension:DataAbsentReason	This element must be supported.	0..1	code	unknown \| asked \| temp \| notasked \| masked \| unsupported \| astext \| error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
ClaimResponse.outcome	This element must be supported. This element is included in summaries.	1..1	code	complete \| error \| partial Binding: Claim Response Outcome (required)
ClaimResponse.preAuthPeriod	This element must be supported.	0..1	Period	Preauthorization reference effective period
ClaimResponse.item	This element must be supported.	0..*	BackboneElement	Adjudication for claim line items
ClaimResponse.item.Slices for extension				Content/Rules for all slices
ClaimResponse.item.Slices for extension.extension:itemTraceNumber	This element must be supported.	0..*	PASIdentifier(2.2.1)	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
ClaimResponse.item.Slices for extension.extension:preAuthIssueDate	This element must be supported.	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
ClaimResponse.item.Slices for extension.extension:preAuthPeriod	This element must be supported.	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
ClaimResponse.item.Slices for extension.extension:previousAuthorizationNumber	This element must be supported.	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
ClaimResponse.item.Slices for extension.extension:administrationReferenceNumber	This element must be supported.	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
ClaimResponse.item.Slices for extension.extension:requestedServiceDate	This element must be supported.	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
ClaimResponse.item.Slices for extension.extension:authorizedProvider	This element must be supported.	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
ClaimResponse.item.Slices for extension.extension:authorizedItemDetail	This element must be supported.	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
ClaimResponse.item.Slices for extension.extension:admissionDates	This element must be supported.	0..1	date	The authorized admission dates for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
ClaimResponse.item.Slices for extension.extension:dischargeDate	This element must be supported.	0..1	date	The authorized discharge date for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
ClaimResponse.item.Slices for extension.extension:communicatedDiagnosis	This element must be supported.	0..*	CodeableConcept	A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.1) (required)
ClaimResponse.item.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.itemSequence	This element must be supported.	1..1	positiveInt	Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
ClaimResponse.item.noteNumber	This element must be supported.	0..*	positiveInt	Applicable note numbers
ClaimResponse.item.adjudication	This element must be supported.	1..*	BackboneElement	Adjudication details
ClaimResponse.item.adjudication.Slices for extension				Content/Rules for all slices
ClaimResponse.item.adjudication.Slices for extension.extension:reviewAction	This element must be supported.	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
ClaimResponse.item.adjudication.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.adjudication.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
ClaimResponse.item.adjudication.category.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.item.adjudication.category.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
ClaimResponse.item.adjudication.category.coding.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.coding.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.item.adjudication.category.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.adjudication.category.coding.version		0..1	string	Version of the system - if relevant
ClaimResponse.item.adjudication.category.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
ClaimResponse.item.adjudication.category.coding.display		0..1	string	Representation defined by the system
ClaimResponse.item.adjudication.category.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
ClaimResponse.item.adjudication.category.text		0..1	string	Plain text representation of the concept
ClaimResponse.addItem	This element must be supported.	0..*	BackboneElement	Insurer added line items
ClaimResponse.addItem.Slices for extension				Content/Rules for all slices
ClaimResponse.addItem.Slices for extension.extension:itemTraceNumber	This element must be supported.	0..*	PASIdentifier(2.2.1)	Item Trace Number URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
ClaimResponse.addItem.Slices for extension.extension:preAuthIssueDate	This element must be supported.	0..1	date	Item Preauthorization Issue Date URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
ClaimResponse.addItem.Slices for extension.extension:preAuthPeriod	This element must be supported.	0..1	Period	Item Preauthorization Period URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
ClaimResponse.addItem.Slices for extension.extension:previousAuthorizationNumber	This element must be supported.	0..1	string	Authorization Number URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
ClaimResponse.addItem.Slices for extension.extension:administrationReferenceNumber	This element must be supported.	0..1	string	Administration Reference Number URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
ClaimResponse.addItem.Slices for extension.extension:epsdtIndicator	This element must be supported.	0..1	boolean	EPSDT Indicator URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
ClaimResponse.addItem.Slices for extension.extension:nursingHomeResidentialStatus	This element must be supported.	0..1	CodeableConcept	Nursing Home Residential Status URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
ClaimResponse.addItem.Slices for extension.extension:nursingHomeLevelOfCare	This element must be supported.	0..1	CodeableConcept	Nursing Home Level of Care 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.
ClaimResponse.addItem.Slices for extension.extension:productOrServiceCodeEnd	This element must be supported.	0..1	CodeableConcept	Product or Service Code End URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.1) (required)
ClaimResponse.addItem.Slices for extension.extension:revenue	This element must be supported.	0..1	CodeableConcept	Revenue Code URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.1) (required)
ClaimResponse.addItem.Slices for extension.extension:revenueUnitRateLimit	This element must be supported.	0..1	decimal	Revenue Unit Rate Limit URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
ClaimResponse.addItem.Slices for extension.extension:requestedService	This element must be supported.	0..1	Reference(PAS Medication Request(2.2.1) \| PAS Service Request(2.2.1) \| PAS Device Request(2.2.1) \| PAS Nutrition Order(2.2.1))	Requested Service URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
ClaimResponse.addItem.Slices for extension.extension:requestType	This element must be supported.	0..1	CodeableConcept	Service Item Request Type URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
ClaimResponse.addItem.Slices for extension.extension:certificationType	This element must be supported.	0..1	CodeableConcept	Certification Type URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
ClaimResponse.addItem.Slices for extension.extension:category		0..1	CodeableConcept	Claim Response Item Category URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
ClaimResponse.addItem.Slices for extension.extension:admissionDates	This element must be supported.	0..1	date	Admission Dates URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates
ClaimResponse.addItem.Slices for extension.extension:dischargeDate	This element must be supported.	0..1	date	Discharge Date URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate
ClaimResponse.addItem.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.itemSequence	This element must be supported.	1..1	positiveInt	Item sequence number
ClaimResponse.addItem.provider	This element must be supported.	0..*	Reference(PAS Practitioner(2.2.1) \| PAS Organization Base Profile(2.2.1))	Authorized providers
ClaimResponse.addItem.provider.Slices for extension				Content/Rules for all slices
ClaimResponse.addItem.provider.Slices for extension.extension:providerType	This element must be supported.	0..1	CodeableConcept	Authorized Provider Type URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. 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.
ClaimResponse.addItem.productOrService	This element must be supported.	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.1) (required)
ClaimResponse.addItem.modifier	This element must be supported.	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.1) (required)
ClaimResponse.addItem.serviced[x]	This element must be supported.	0..1		Date or dates of service or product delivery
ClaimResponse.addItem.serviced[x].servicedDate			date
ClaimResponse.addItem.serviced[x].servicedPeriod			Period
ClaimResponse.addItem.location[x]	This element must be supported.	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
ClaimResponse.addItem.location[x].locationCodeableConcept			CodeableConcept
ClaimResponse.addItem.location[x].locationAddress			Address
ClaimResponse.addItem.location[x].locationReference			Reference(Location)
ClaimResponse.addItem.quantity	This element must be supported. C	0..1	PASQuantity(2.2.1)	Count of products or services Constraints: sqty-1
ClaimResponse.addItem.unitPrice	This element must be supported.	0..1	Money	Fee, charge or cost per item
ClaimResponse.addItem.adjudication	This element must be supported.	1..*	BackboneElement	Added items adjudication
ClaimResponse.addItem.adjudication.Slices for extension				Content/Rules for all slices
ClaimResponse.addItem.adjudication.Slices for extension.extension:reviewAction	This element must be supported.	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
ClaimResponse.addItem.adjudication.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.adjudication.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
ClaimResponse.addItem.adjudication.category.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.addItem.adjudication.category.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.addItem.adjudication.category.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
ClaimResponse.addItem.adjudication.category.coding.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.addItem.adjudication.category.coding.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.addItem.adjudication.category.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.addItem.adjudication.category.coding.version		0..1	string	Version of the system - if relevant
ClaimResponse.addItem.adjudication.category.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
ClaimResponse.addItem.adjudication.category.coding.display		0..1	string	Representation defined by the system
ClaimResponse.addItem.adjudication.category.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
ClaimResponse.addItem.adjudication.category.text		0..1	string	Plain text representation of the concept
ClaimResponse.adjudication	This element must be supported.	0..*	BackboneElement	Header-level adjudication
ClaimResponse.adjudication.Slices for extension				Content/Rules for all slices
ClaimResponse.adjudication.Slices for extension.extension:reviewAction	This element must be supported.	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
ClaimResponse.adjudication.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.adjudication.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
ClaimResponse.adjudication.category.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.adjudication.category.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.adjudication.category.coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
ClaimResponse.adjudication.category.coding.id		0..1	string	Unique id for inter-element referencing
ClaimResponse.adjudication.category.coding.extension		0..*	Extension	Additional content defined by implementations
ClaimResponse.adjudication.category.coding.system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.adjudication.category.coding.version		0..1	string	Version of the system - if relevant
ClaimResponse.adjudication.category.coding.code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
ClaimResponse.adjudication.category.coding.display		0..1	string	Representation defined by the system
ClaimResponse.adjudication.category.coding.userSelected		0..1	boolean	If this coding was chosen directly by the user
ClaimResponse.adjudication.category.text		0..1	string	Plain text representation of the concept
ClaimResponse.processNote	This element must be supported.	0..*	BackboneElement	Note concerning adjudication
ClaimResponse.processNote.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.processNote.number	This element must be supported.	1..1	positiveInt	Note instance identifier
ClaimResponse.processNote.text	This element must be supported.	1..1	string	Note explanatory text
ClaimResponse.communicationRequest	This element must be supported.	0..*	Reference(PAS CommunicationRequest(2.2.1))	Request for additional information
ClaimResponse.error	This element must be supported.	0..*	BackboneElement	Processing errors
ClaimResponse.error.Slices for extension				Content/Rules for all slices
ClaimResponse.error.Slices for extension.extension:followupAction	This element must be supported.	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: X12278FollowUpActionCodes (2.2.1) (required)
ClaimResponse.error.Slices for extension.extension:errorElement	This element must be supported.	0..1	(Complex)	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
ClaimResponse.error.Slices for extension.extension:errorPath	This element must be supported.	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
ClaimResponse.error.modifierExtension	This element is a modifier element. This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
ClaimResponse.error.code	This element must be supported.	1..1	CodeableConcept	Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.1) (required)
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.identifier.use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.status	Base	required	Financial Resource Status Codes	📍4.0.1	FHIR Std.
ClaimResponse.type	Base	extensible	Claim Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.use	Base	required	Use	📍4.0.1	FHIR Std.
ClaimResponse.outcome	Base	required	Claim Response Outcome	📦2.2.1	This IG
ClaimResponse.item.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.productOrService	Base	required	X12 278 Requested Service Type	📍2.2.1	This IG
ClaimResponse.addItem.modifier	Base	required	X12 278 Requested Service Modifier Type	📍2.2.1	This IG
ClaimResponse.addItem.location[x]	Base	example	Example Service Place Codes	📍4.0.1	FHIR Std.
ClaimResponse.addItem.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.adjudication.category	Base	example	Adjudication Value Codes	📍4.0.1	FHIR Std.
ClaimResponse.error.code	Base	required	X12 278 Reject Reason Value Set	📍2.2.1	This IG

Constraints

Grade

Path(s)

Description

Expression

Differential View

This structure is derived from PASClaimResponseBase

Name	Flags	Card.	Type	Description & Constraints Filter: Bindings Constraints Obligations
ClaimResponse		0..*	PASClaimResponseBase(2.2.1)	Response to a preauthorization
ClaimResponse.item
ClaimResponse.item.Slices for extension				Content/Rules for all slices
ClaimResponse.item.Slices for extension.extension:communicatedDiagnosis	This element must be supported.	0..*	CodeableConcept	A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.1) (required)
ClaimResponse.communicationRequest	This element must be supported.	0..*	Reference(PAS CommunicationRequest(2.2.1))	Request for additional information
Documentation for this format

Snapshot ViewView

Description & Constraints Filter:

ClaimResponse

0..*

PASClaimResponseBase(2.2.1)

Response to a preauthorization

0..1

Logical id of this artifact

1..1

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

0..*

Adjudication for claim details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

detailSequence

1..1

Claim detail instance identifier

0..*

Applicable note numbers

1..*

Detail level adjudication details

0..*

Adjudication for claim sub-details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Claim sub-detail instance identifier

0..*

Applicable note numbers

0..*

Subdetail level adjudication details

addItem

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..*

extension:itemTraceNumber

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

0..*

PASIdentifier(2.2.1)

Item Trace Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber

extension:preAuthIssueDate

0..1

Item Preauthorization Issue Date
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate

extension:preAuthPeriod

0..1

extension:previousAuthorizationNumber

Item Preauthorization Period
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod

0..1

extension:administrationReferenceNumber

Authorization Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber

0..1

Administration Reference Number
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber

extension:epsdtIndicator

0..1

extension:nursingHomeResidentialStatus

EPSDT Indicator
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator

0..1

extension:nursingHomeLevelOfCare

Nursing Home Residential Status
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus

0..1

extension:productOrServiceCodeEnd

0..1

Product or Service Code End
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12278RequestedServiceType (2.2.1) (required)

extension:revenue

0..1

extension:revenueUnitRateLimit

Revenue Code
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode
Binding: AHANUBCRevenueCodes (2.2.1) (required)

0..1

extension:requestedService

Revenue Unit Rate Limit
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit

0..1

Reference(PAS Medication Request(2.2.1) | PAS Service Request(2.2.1) | PAS Device Request(2.2.1) | PAS Nutrition Order(2.2.1))

Requested Service
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

extension:requestType

0..1

extension:certificationType

0..1

extension:category

0..1

extension:admissionDates

0..1

Admission Dates
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-admissionDates

extension:dischargeDate

0..1

Discharge Date
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-dischargeDate

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Item sequence number

0..*

Detail sequence number

subdetailSequence

0..*

Reference(PAS Practitioner(2.2.1) | PAS Organization Base Profile(2.2.1))

Subdetail sequence number

provider

0..*

Authorized providers

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations
Slice: Unordered, Open by value:url

extension:providerType

0..1

reference

0..1

Literal reference, Relative, internal or absolute URL

0..1

Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

0..1

Logical reference, when literal reference is not known

0..1

Text alternative for the resource

1..1

Billing, service, product, or drug code
Binding: X12278RequestedServiceType (2.2.1) (required)

0..*

Service/Product billing modifiers
Binding: X12278RequestedServiceModifierType (2.2.1) (required)

programCode

0..*

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

serviced[x]

0..1

Date or dates of service or product delivery

servicedDate

servicedPeriod

location[x]

0..1

Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

locationCodeableConcept

locationAddress

locationReference

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

bodySite

0..1

Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

subSite

0..*

Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.

0..*

Applicable note numbers

1..*

Added items adjudication

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

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

0..*

Extensions that cannot be ignored even if unrecognized

1..1

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

0..*

Insurer added line details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..*

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

0..*

Applicable note numbers

1..*

Added items detail adjudication

0..*

Insurer added line items

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

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

0..*

0..1

Count of products or services
Constraints: sqty-1

0..1

Fee, charge or cost per item

0..1

Price scaling factor

net

0..1

Total item cost

0..*

Applicable note numbers

1..*

Added items detail adjudication

0..*

Header-level adjudication

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

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

0..*

Extensions that cannot be ignored even if unrecognized

1..1

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..*

Code defined by a terminology system
Fixed Value: (Complex)

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

1..1

Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication

0..1

Version of the system - if relevant

1..1

Symbol in syntax defined by the system
Fixed Value: submitted

0..1

Representation defined by the system

0..1

If this coding was chosen directly by the user

0..1

Plain text representation of the concept

0..1

Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

0..1

Monetary amount

0..1

Non-monetary value

total

0..*

Adjudication totals

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

1..1

Financial total for the category

payment

0..1

Payment Details

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

1..1

Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

adjustment

0..1

Payment adjustment for non-claim issues

adjustmentReason

0..1

Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

0..1

Expected date of payment

1..1

Payable amount after adjustment

0..1

Business identifier for the payment

fundsReserve

0..1

Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

formCode

0..1

Printed form identifier
Binding: Form Codes (example): The forms codes.

form

0..1

Attachment

Printed reference or actual form

processNote

0..*

Note concerning adjudication

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

number

1..1

Note instance identifier

0..1

display | print | printoper
Binding: NoteType (required): The presentation types of notes.

1..1

Note explanatory text

language

0..1

Reference(PAS CommunicationRequest(2.2.1))

Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional Bindings

Purpose

AllLanguages

Max Binding

communicationRequest

0..*

Request for additional information

insurance

0..*

Patient insurance information

0..1

Unique id for inter-element referencing

0..*

Additional content defined by implementations

0..*

Extensions that cannot be ignored even if unrecognized

sequence

1..1

Insurance instance identifier

focal

1..1

Coverage to be used for adjudication

coverage

1..1

Reference(Coverage)

Insurance information

businessArrangement

0..1

Additional provider contract number

claimResponse

0..1

Reference(ClaimResponse)

Adjudication results

error

0..*

Processing errors

0..1

Unique id for inter-element referencing

0..*

Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them

extension:followupAction

0..1

extension:errorElement

0..1

(Complex)

The specific X12 loop, segment, or element that this error information is about.
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement

extension:errorPath

0..1

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

0..*

Extensions that cannot be ignored even if unrecognized

0..1

Item sequence number

0..1

Detail sequence number

0..1

Subdetail sequence number

1..1