Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot

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 2.2.0-ballot 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

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim | Version: 2.2.0-ballot
Standards status: Trial-use | Maturity Level: 3 | Computable Name: PASClaim
Other Identifiers: OID:2.16.840.1.113883.4.642.40.24.42.49

PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request

Usages:

- Use this Profile: PAS Request Bundle
- Refer to this Profile: PAS Claim Response Base and PAS Task
- Examples for this Profile: Claim/HomecareAuthorizationExample, Claim/MedicalServicesAuthorizationExample, Claim/ReferralAuthorizationExample and Claim/SurgicalAuthorizationRequestExample

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:conditionCode | S | 0..* | (Complex) | Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
extension:homeHealthCareInformation | S | 0..1 | (Complex) | Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..2 | PASIdentifier | Business identifier for claim
Slices for extension |  |  |  | Content/Rules for all slices
extension:subDepartment | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | S Σ | 1..1 | uri | SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | Resource creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization) | Target
provider | S Σ | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: true
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: false
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent | S | 0..1 | BackboneElement | Information about the dates of the event that are being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientEvent
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
supportingInfo:AdmissionDates | S | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
supportingInfo:DischargeDates | S | 0..1 | BackboneElement | Information about the discharge dates of a hospital admission being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dischargeDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
timing[x] | S C | 1..1 | date | When it occurred Constraints: FullDateRule
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value[x] | S | 1..1 | string | Data to be provided
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type | S | 0..1 | CodeableConcept | Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance | S Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Required Pattern: true
coverage | S Σ | 1..1 | Reference(PAS Coverage) | Insurance information
accident | S | 0..1 | BackboneElement | Details of the event
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date | S C | 1..1 | date | When the incident occurred Constraints: FullDateRule
type | S | 0..1 | CodeableConcept | The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x] | S | 0..1 | Address | Where the event occurred
item | S C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestType | S | 1..1 | CodeableConcept | Extension 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.
extension:certificationType | S | 1..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
careTeamSequence | S | 0..* | positiveInt | Applicable careTeam members
diagnosisSequence | S | 0..* | positiveInt | Applicable diagnoses
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information
revenue | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category | S | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
Slices for serviced[x] | S | 0..1 |  | Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
serviced[x]:servicedDate | S C | 0..1 | date | Date or dates of service or product delivery Constraints: FullDateRule
serviced[x]:servicedPeriod | S | 0..1 | Period | Date or dates of service or product delivery
location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity | S | 0..1 | PASQuantity | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Claim.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Claim.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Claim.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
Claim.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
Claim.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` From the FHIR Standard
Claim.careTeam.role | example | ClaimCareTeamRoleCodes `http://hl7.org/fhir/ValueSet/claim-careteamrole` From the FHIR Standard
Claim.careTeam.qualification | example | ExampleProviderQualificationCodes `http://hl7.org/fhir/ValueSet/provider-qualification` From the FHIR Standard
Claim.careTeam:OverallClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98`
Claim.careTeam:OverallClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127`
Claim.careTeam:ItemClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98`
Claim.careTeam:ItemClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127`
Claim.supportingInfo.category | extensible | PASSupportingInfoType `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:PatientEvent.category | extensible | Pattern Value: patientEvent `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdmissionDates.category | extensible | Pattern Value: admissionDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:DischargeDates.category | extensible | Pattern Value: dischargeDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdditionalInformation.category | extensible | Pattern Value: additionalInformation `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:MessageText.category | extensible | Pattern Value: freeFormMessage `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.diagnosis.diagnosis[x] | required | X12278DiagnosisCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisCodes` From this IG
Claim.diagnosis.type | required | X12278DiagnosisType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisType` From this IG
Claim.accident.type | required | https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 `https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362`
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`
Claim.item.revenue | required | AHANUBCRevenueCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/AHANUBCRevenueCodes` From this IG
Claim.item.category | required | https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 `https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365`
Claim.item.productOrService | required | X12278RequestedServiceType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType` From this IG
Claim.item.modifier | required | X12278RequestedServiceModifierType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType` From this IG
Claim.item.location[x] | required | X12278LocationType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278LocationType` From this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
FullDateRule | error | Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x], Claim.accident.date, Claim.item.serviced[x]:servicedDate | Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10 |
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |
dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from PASClaimBase

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
Slices for extension |  |  |  | Content/Rules for all slices
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
identifier |  | 1..2 | PASIdentifier | Business identifier for claim
related |  | 0..0 |  |
Slices for supportingInfo |  |  |  | Content/Rules for all slices
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
category |  | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
timing[x] |  | 0..0 |  |
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
category |  | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
timing[x] |  | 0..0 |  |
value[x] | S | 1..1 | string | Data to be provided
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
item | C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
extension |  | 2..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:requestType |  | 1..1 | ServiceItemRequestType | Extension
extension:certificationType |  | 1..1 | CertificationType | Extension
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
category |  | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
location[x] |  | 1..1 | CodeableConcept | Place of service or where product was supplied
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:conditionCode | S | 0..* | (Complex) | Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
extension:homeHealthCareInformation | S | 0..1 | (Complex) | Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..2 | PASIdentifier | Business identifier for claim
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:subDepartment | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | S Σ | 1..1 | uri | SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | Resource creation date
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization) | Target
provider | S Σ | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
prescription |  | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products
originalPrescription |  | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment referral
facility |  | 0..1 | Reference(Location) | Servicing facility
Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: true
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: false
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent | S | 0..1 | BackboneElement | Information about the dates of the event that are being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientEvent
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates | S | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates | S | 0..1 | BackboneElement | Information about the discharge dates of a hospital admission being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dischargeDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] | S C | 1..1 | date | When it occurred Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x] | S | 1..1 | string | Data to be provided
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type | S | 0..1 | CodeableConcept | Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
insurance | S Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Required Pattern: true
identifier |  | 0..1 | Identifier | Pre-assigned Claim number
coverage | S Σ | 1..1 | Reference(PAS Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
preAuthRef |  | 0..* | string | Prior authorization reference number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
accident | S | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date | S C | 1..1 | date | When the incident occurred Constraints: FullDateRule
type | S | 0..1 | CodeableConcept | The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x] | S | 0..1 | Address | Where the event occurred
item | S C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestType | S | 1..1 | CodeableConcept | Extension 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.
extension:certificationType | S | 1..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
careTeamSequence | S | 0..* | positiveInt | Applicable careTeam members
diagnosisSequence | S | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information
revenue | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category | S | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x] | S | 0..1 |  | Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
serviced[x]:servicedDate | S C | 0..1 | date | Date or dates of service or product delivery Constraints: FullDateRule
serviced[x]:servicedPeriod | S | 0..1 | Period | Date or dates of service or product delivery
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity | S | 0..1 | PASQuantity | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
detail |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
subDetail |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
total |  | 0..1 | Money | Total claim cost
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Claim.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Claim.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Claim.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Claim.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Claim.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
Claim.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype` From the FHIR Standard
Claim.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
Claim.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` From the FHIR Standard
Claim.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve` From the FHIR Standard
Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodes `http://hl7.org/fhir/ValueSet/related-claim-relationship` From the FHIR Standard
Claim.payee.type | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype` From the FHIR Standard
Claim.careTeam.role | example | ClaimCareTeamRoleCodes `http://hl7.org/fhir/ValueSet/claim-careteamrole` From the FHIR Standard
Claim.careTeam.qualification | example | ExampleProviderQualificationCodes `http://hl7.org/fhir/ValueSet/provider-qualification` From the FHIR Standard
Claim.careTeam:OverallClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98`
Claim.careTeam:OverallClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127`
Claim.careTeam:ItemClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98`
Claim.careTeam:ItemClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127`
Claim.supportingInfo.category | extensible | PASSupportingInfoType `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:PatientEvent.category | extensible | Pattern Value: patientEvent `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:PatientEvent.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:PatientEvent.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:AdmissionDates.category | extensible | Pattern Value: admissionDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdmissionDates.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:AdmissionDates.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:DischargeDates.category | extensible | Pattern Value: dischargeDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:DischargeDates.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:DischargeDates.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:AdditionalInformation.category | extensible | Pattern Value: additionalInformation `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdditionalInformation.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:AdditionalInformation.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:MessageText.category | extensible | Pattern Value: freeFormMessage `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:MessageText.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:MessageText.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.diagnosis.diagnosis[x] | required | X12278DiagnosisCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisCodes` From this IG
Claim.diagnosis.type | required | X12278DiagnosisType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisType` From this IG
Claim.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission` From the FHIR Standard
Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup` From the FHIR Standard
Claim.procedure.type | example | ExampleProcedureTypeCodes `http://hl7.org/fhir/ValueSet/ex-procedure-type` From the FHIR Standard
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodes `http://hl7.org/fhir/ValueSet/icd-10-procedures` From the FHIR Standard
Claim.accident.type | required | https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 `https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362`
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`
Claim.item.revenue | required | AHANUBCRevenueCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/AHANUBCRevenueCodes` From this IG
Claim.item.category | required | https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 `https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365`
Claim.item.productOrService | required | X12278RequestedServiceType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType` From this IG
Claim.item.modifier | required | X12278RequestedServiceModifierType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType` From this IG
Claim.item.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
Claim.item.location[x] | required | X12278LocationType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278LocationType` From this IG
Claim.item.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth` From the FHIR Standard
Claim.item.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface` From the FHIR Standard
Claim.item.detail.revenue | example | ExampleRevenueCenterCodes `http://hl7.org/fhir/ValueSet/ex-revenue-center` From the FHIR Standard
Claim.item.detail.category | example | BenefitCategoryCodes `http://hl7.org/fhir/ValueSet/ex-benefitcategory` From the FHIR Standard
Claim.item.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
Claim.item.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
Claim.item.detail.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes `http://hl7.org/fhir/ValueSet/ex-revenue-center` From the FHIR Standard
Claim.item.detail.subDetail.category | example | BenefitCategoryCodes `http://hl7.org/fhir/ValueSet/ex-benefitcategory` From the FHIR Standard
Claim.item.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
Claim.item.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
FullDateRule | error | Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x], Claim.accident.date, Claim.item.serviced[x]:servicedDate, Claim.item.serviced[x]:servicedPeriod.start, Claim.item.serviced[x]:servicedPeriod.end | Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10 |
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |
dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from PASClaimBase

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 14 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

- PAS Encounter (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter)
- PAS Document Reference (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-documentreference)
- US Core QuestionnaireResponse Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-questionnaireresponse|7.0.0)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

Maturity: 3

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:conditionCode | S | 0..* | (Complex) | Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
extension:homeHealthCareInformation | S | 0..1 | (Complex) | Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..2 | PASIdentifier | Business identifier for claim
Slices for extension |  |  |  | Content/Rules for all slices
extension:subDepartment | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | S Σ | 1..1 | uri | SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | Resource creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization) | Target
provider | S Σ | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: true
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: false
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent | S | 0..1 | BackboneElement | Information about the dates of the event that are being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientEvent
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
supportingInfo:AdmissionDates | S | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
supportingInfo:DischargeDates | S | 0..1 | BackboneElement | Information about the discharge dates of a hospital admission being requested.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dischargeDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
timing[x] | S C | 1..1 | date | When it occurred Constraints: FullDateRule
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
value[x] | S | 1..1 | string | Data to be provided
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type | S | 0..1 | CodeableConcept | Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance | S Σ | 1..* | BackboneElement | Patient insurance information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Required Pattern: true
coverage | S Σ | 1..1 | Reference(PAS Coverage) | Insurance information
accident | S | 0..1 | BackboneElement | Details of the event
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date | S C | 1..1 | date | When the incident occurred Constraints: FullDateRule
type | S | 0..1 | CodeableConcept | The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x] | S | 0..1 | Address | Where the event occurred
item | S C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestType | S | 1..1 | CodeableConcept | Extension 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.
extension:certificationType | S | 1..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
careTeamSequence | S | 0..* | positiveInt | Applicable careTeam members
diagnosisSequence | S | 0..* | positiveInt | Applicable diagnoses
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information
revenue | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category | S | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
Slices for serviced[x] | S | 0..1 |  | Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
serviced[x]:servicedDate | S C | 0..1 | date | Date or dates of service or product delivery Constraints: FullDateRule
serviced[x]:servicedPeriod | S | 0..1 | Period | Date or dates of service or product delivery
location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity | S | 0..1 | PASQuantity | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Claim.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Claim.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Claim.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
Claim.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
Claim.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` From the FHIR Standard
Claim.careTeam.role | example | ClaimCareTeamRoleCodes `http://hl7.org/fhir/ValueSet/claim-careteamrole` From the FHIR Standard
Claim.careTeam.qualification | example | ExampleProviderQualificationCodes `http://hl7.org/fhir/ValueSet/provider-qualification` From the FHIR Standard
Claim.careTeam:OverallClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98`
Claim.careTeam:OverallClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127`
Claim.careTeam:ItemClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98`
Claim.careTeam:ItemClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127`
Claim.supportingInfo.category | extensible | PASSupportingInfoType `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:PatientEvent.category | extensible | Pattern Value: patientEvent `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdmissionDates.category | extensible | Pattern Value: admissionDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:DischargeDates.category | extensible | Pattern Value: dischargeDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdditionalInformation.category | extensible | Pattern Value: additionalInformation `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:MessageText.category | extensible | Pattern Value: freeFormMessage `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.diagnosis.diagnosis[x] | required | X12278DiagnosisCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisCodes` From this IG
Claim.diagnosis.type | required | X12278DiagnosisType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisType` From this IG
Claim.accident.type | required | https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 `https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362`
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`
Claim.item.revenue | required | AHANUBCRevenueCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/AHANUBCRevenueCodes` From this IG
Claim.item.category | required | https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 `https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365`
Claim.item.productOrService | required | X12278RequestedServiceType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType` From this IG
Claim.item.modifier | required | X12278RequestedServiceModifierType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType` From this IG
Claim.item.location[x] | required | X12278LocationType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278LocationType` From this IG

#### Constraints

Id | Grade | Path(s) | Details | Requirements
FullDateRule | error | Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x], Claim.accident.date, Claim.item.serviced[x]:servicedDate | Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10 |
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |
dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

Differential View

This structure is derived from PASClaimBase

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
Slices for extension |  |  |  | Content/Rules for all slices
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
identifier |  | 1..2 | PASIdentifier | Business identifier for claim
related |  | 0..0 |  |
Slices for supportingInfo |  |  |  | Content/Rules for all slices
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
category |  | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
timing[x] |  | 0..0 |  |
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
category |  | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
timing[x] |  | 0..0 |  |
value[x] | S | 1..1 | string | Data to be provided
diagnosis |  | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
item | C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
extension |  | 2..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:requestType |  | 1..1 | ServiceItemRequestType | Extension
extension:certificationType |  | 1..1 | CertificationType | Extension
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
category |  | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
location[x] |  | 1..1 | CodeableConcept | Place of service or where product was supplied
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Claim |  | 0..* | PASClaimBase | Preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:conditionCode | S | 0..* | (Complex) | Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
extension:homeHealthCareInformation | S | 0..1 | (Complex) | Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
extension:encounter | S | 0..1 | (Complex) | Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x] |  | 1..1 | Reference(PAS Encounter) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..2 | PASIdentifier | Business identifier for claim
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
extension:subDepartment | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
extension:jurisdiction | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: UspsTwoLetterAlphabeticCodes (7.0.0) (required)
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | S Σ | 1..1 | uri | SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim
created | Σ | 1..1 | dateTime | Resource creation date
enterer |  | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization) | Target
provider | S Σ | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim
priority | Σ | 1..1 | CodeableConcept | Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve |  | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
prescription |  | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Prescription authorizing services and products
originalPrescription |  | 0..1 | Reference(DeviceRequest | MedicationRequest | VisionPrescription) | Original prescription if superseded by fulfiller
payee |  | 0..1 | BackboneElement | Recipient of benefits payable
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson) | Recipient reference
referral |  | 0..1 | Reference(ServiceRequest) | Treatment referral
facility |  | 0..1 | Reference(Location) | Servicing facility
Slices for careTeam | S | 0..* | BackboneElement | Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: true
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember | S | 0..* | BackboneElement | Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:careTeamClaimScope | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x] | S | 0..1 | boolean | Value of extension Fixed Value: false
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Order of care team
provider | S | 1..1 | Reference(PAS Organization Base Profile | PAS PractitionerRole) | Practitioner or organization
responsible |  | 0..1 | boolean | Indicator of the lead practitioner
role | S | 0..1 | CodeableConcept | Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification | S | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] |  | 0..1 |  | When it occurred
timingDate |  |  | date |
timingPeriod |  |  | Period |
value[x] |  | 0..1 |  | Data to be provided
valueBoolean |  |  | boolean |
valueString |  |  | string |
valueQuantity |  |  | Quantity |
valueAttachment |  |  | Attachment |
valueReference |  |  | Reference(Resource) |
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent | S | 0..1 | BackboneElement | Information about the dates of the event that are being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: patientEvent
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates | S | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x] | S | 1..1 |  | When it occurred Slice: Unordered, Closed by type:$this
timingDate |  |  | date |
timingPeriod |  |  | Period |
timing[x]:timingDate | S C | 0..1 | date | When it occurred Constraints: FullDateRule
timing[x]:timingPeriod | S | 0..1 | Period | When it occurred
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | S Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | S Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates | S | 0..1 | BackboneElement | Information about the discharge dates of a hospital admission being requested.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: dischargeDates
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x] | S C | 1..1 | date | When it occurred Constraints: FullDateRule
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation | S | 0..* | BackboneElement | Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:documentInformation | S | 1..1 | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: additionalInformation
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x] | S | 1..1 | Reference(PAS Document Reference | US Core QuestionnaireResponse Profile(7.0.0) | Resource) | Data to be provided
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText | S | 0..* | BackboneElement | Send text messages to the UMO.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Information instance identifier
category | S | 1..1 | CodeableConcept | Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: freeFormMessage
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
code |  | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x] | S | 1..1 | string | Data to be provided
reason |  | 0..1 | CodeableConcept | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis | S | 0..* | BackboneElement | Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:recordedDate | S | 0..1 | date | The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Diagnosis instance identifier
diagnosis[x] | S | 1..1 | CodeableConcept | Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type | S | 0..1 | CodeableConcept | Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission |  | 0..1 | CodeableConcept | Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode |  | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure |  | 0..* | BackboneElement | Clinical procedures performed
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Procedure instance identifier
type |  | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date |  | 0..1 | dateTime | When the procedure was performed
procedure[x] |  | 1..1 |  | Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept |  |  | CodeableConcept |
procedureReference |  |  | Reference(Procedure) |
udi |  | 0..* | Reference(Device) | Unique device identifier
insurance | S Σ | 1..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S Σ | 1..1 | positiveInt | Insurance instance identifier
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication Required Pattern: true
identifier |  | 0..1 | Identifier | Pre-assigned Claim number
coverage | S Σ | 1..1 | Reference(PAS Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
preAuthRef |  | 0..* | string | Prior authorization reference number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
accident | S | 0..1 | BackboneElement | Details of the event
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
date | S C | 1..1 | date | When the incident occurred Constraints: FullDateRule
type | S | 0..1 | CodeableConcept | The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x] | S | 0..1 | Address | Where the event occurred
item | S C | 1..* | BackboneElement | Product or service provided Constraints: ImmediateLevelOfCare
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:requestType | S | 1..1 | CodeableConcept | Extension 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.
extension:certificationType | S | 1..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension:epsdtIndicator | S | 0..1 | boolean | An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | (Complex) | A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x] | S | 0..1 | CodeableConcept | Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
extension:revenueUnitRateLimit | S | 0..1 | decimal | The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order) | The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
careTeamSequence | S | 0..* | positiveInt | Applicable careTeam members
diagnosisSequence | S | 0..* | positiveInt | Applicable diagnoses
procedureSequence |  | 0..* | positiveInt | Applicable procedures
informationSequence | S | 0..* | positiveInt | Applicable exception and supporting information
revenue | S | 0..1 | CodeableConcept | Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category | S | 1..1 | CodeableConcept | Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier | S | 0..* | CodeableConcept | Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x] | S | 0..1 |  | Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
serviced[x]:servicedDate | S C | 0..1 | date | Date or dates of service or product delivery Constraints: FullDateRule
serviced[x]:servicedPeriod | S | 0..1 | Period | Date or dates of service or product delivery
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
start | Σ C | 0..1 | dateTime | Starting time with inclusive boundary Constraints: FullDateRule
end | Σ C | 0..1 | dateTime | End time with inclusive boundary, if not ongoing Constraints: FullDateRule
location[x] | S | 1..1 | CodeableConcept | Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity | S | 0..1 | PASQuantity | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter |  | 0..* | Reference(Encounter) | Encounters related to this billed item
detail |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
subDetail |  | 0..* | BackboneElement | Product or service provided
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Item instance identifier
revenue |  | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category |  | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
udi |  | 0..* | Reference(Device) | Unique device identifier
total |  | 0..1 | Money | Total claim cost
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
Claim.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
Claim.identifier.use | required | IdentifierUse `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` From the FHIR Standard
Claim.identifier.type | extensible | Identifier Type Codes `http://hl7.org/fhir/ValueSet/identifier-type` From the FHIR Standard
Claim.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
Claim.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
Claim.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype` From the FHIR Standard
Claim.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
Claim.priority | example | ProcessPriorityCodes `http://hl7.org/fhir/ValueSet/process-priority` From the FHIR Standard
Claim.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve` From the FHIR Standard
Claim.related.relationship | example | ExampleRelatedClaimRelationshipCodes `http://hl7.org/fhir/ValueSet/related-claim-relationship` From the FHIR Standard
Claim.payee.type | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype` From the FHIR Standard
Claim.careTeam.role | example | ClaimCareTeamRoleCodes `http://hl7.org/fhir/ValueSet/claim-careteamrole` From the FHIR Standard
Claim.careTeam.qualification | example | ExampleProviderQualificationCodes `http://hl7.org/fhir/ValueSet/provider-qualification` From the FHIR Standard
Claim.careTeam:OverallClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98`
Claim.careTeam:OverallClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127`
Claim.careTeam:ItemClaimMember.role | required | https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 `https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98`
Claim.careTeam:ItemClaimMember.qualification | required | https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 `https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127`
Claim.supportingInfo.category | extensible | PASSupportingInfoType `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:PatientEvent.category | extensible | Pattern Value: patientEvent `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:PatientEvent.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:PatientEvent.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:AdmissionDates.category | extensible | Pattern Value: admissionDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdmissionDates.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:AdmissionDates.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:DischargeDates.category | extensible | Pattern Value: dischargeDates `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:DischargeDates.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:DischargeDates.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:AdditionalInformation.category | extensible | Pattern Value: additionalInformation `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:AdditionalInformation.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:AdditionalInformation.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.supportingInfo:MessageText.category | extensible | Pattern Value: freeFormMessage `http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType` From this IG
Claim.supportingInfo:MessageText.code | example | ExceptionCodes `http://hl7.org/fhir/ValueSet/claim-exception` From the FHIR Standard
Claim.supportingInfo:MessageText.reason | example | MissingToothReasonCodes `http://hl7.org/fhir/ValueSet/missing-tooth-reason` From the FHIR Standard
Claim.diagnosis.diagnosis[x] | required | X12278DiagnosisCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisCodes` From this IG
Claim.diagnosis.type | required | X12278DiagnosisType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisType` From this IG
Claim.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes `http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission` From the FHIR Standard
Claim.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes `http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup` From the FHIR Standard
Claim.procedure.type | example | ExampleProcedureTypeCodes `http://hl7.org/fhir/ValueSet/ex-procedure-type` From the FHIR Standard
Claim.procedure.procedure[x] | example | ICD-10ProcedureCodes `http://hl7.org/fhir/ValueSet/icd-10-procedures` From the FHIR Standard
Claim.accident.type | required | https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 `https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362`
Claim.item.extension:nursingHomeResidentialStatus.value[x] | required | https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 `https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345`
Claim.item.revenue | required | AHANUBCRevenueCodes `http://hl7.org/fhir/us/davinci-pas/ValueSet/AHANUBCRevenueCodes` From this IG
Claim.item.category | required | https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 `https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365`
Claim.item.productOrService | required | X12278RequestedServiceType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType` From this IG
Claim.item.modifier | required | X12278RequestedServiceModifierType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType` From this IG
Claim.item.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
Claim.item.location[x] | required | X12278LocationType `http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278LocationType` From this IG
Claim.item.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth` From the FHIR Standard
Claim.item.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface` From the FHIR Standard
Claim.item.detail.revenue | example | ExampleRevenueCenterCodes `http://hl7.org/fhir/ValueSet/ex-revenue-center` From the FHIR Standard
Claim.item.detail.category | example | BenefitCategoryCodes `http://hl7.org/fhir/ValueSet/ex-benefitcategory` From the FHIR Standard
Claim.item.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
Claim.item.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
Claim.item.detail.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
Claim.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes `http://hl7.org/fhir/ValueSet/ex-revenue-center` From the FHIR Standard
Claim.item.detail.subDetail.category | example | BenefitCategoryCodes `http://hl7.org/fhir/ValueSet/ex-benefitcategory` From the FHIR Standard
Claim.item.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
Claim.item.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
Claim.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
FullDateRule | error | Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x], Claim.accident.date, Claim.item.serviced[x]:servicedDate, Claim.item.serviced[x]:servicedPeriod.start, Claim.item.serviced[x]:servicedPeriod.end | Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10 |
ImmediateLevelOfCare | error | Claim.item | If Certification Type is an immediate appeal, then Level of Service Code must be present : extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType' and value.code='1').exists() implies extension.where(url='http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode').exists() |
dom-2 | error | Claim | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | Claim | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | Claim | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | Claim | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from PASClaimBase

Summary

Mandatory: 6 elements(4 nested mandatory elements)
Must-Support: 14 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

- PAS Encounter (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter)
- PAS Document Reference (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-documentreference)
- US Core QuestionnaireResponse Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-questionnaireresponse|7.0.0)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

Maturity: 3

Other representations of profile: CSV, Excel, Schematron