# PAS Claim Update - Da Vinci Prior Authorization Support (PAS) FHIR IG v2.2.0-ballot

## Resource Profile: PAS Claim Update 

 
This profile defines constraints and extensions used when updating a previously submitted Claim instance. 
* The Claim instance of the update Bundle SHALL reference the updated Claim instance within the `Claim.related.claim` element. Note that the presence of this reference and the requirement that referenced instances be included in the submitted Bundle implies that the instance representing the prior version of the Claim SHALL be included in the update Bundle.
* The Claim instance of the update Bundle SHALL contain within the `Claim.item` element each item requested in the updated claim and any prior versions of the claim, including requested items that have been added, modified, deleted, or left unchanged during this or previous updates.
* The Claim instance of the update Bundle SHALL contain within the `Claim.supportingInfo` element each piece of supporting documentation submitted with the updated claim and any prior versions of claim, including supporting documentation that has been added, modified, deleted, or left unchanged during this or previous updates.
* Each `Claim.item` entry that represents an item no longer being requested, whether removed in this update or a previous one, SHALL be flagged using the infoCancelledFlag modifierExtension and SHALL have the code `3` (Cancel) in the Certification Type extension.
* Each `Claim.supportingInfo` entry that is no longer to be used when evaluating the request, whether removed in this update or a previous one, SHALL be flagged using the infoCancelledFlag modifierExtension.
* Each `Claim.item` and `Claim.supportingInfo` entry that has been changed as a part of this most recent update, including removal, SHALL be flagged using the changed extension with a value of `changed`.
* Each `Claim.item` and `Claim.supportingInfo` entry that has been added as a part of this most recent update, SHALL be flagged using the changed extension with a value of `added`.
 

**Usages:**

* Use this Profile: [PAS Request Bundle](StructureDefinition-profile-pas-request-bundle.md) and [PAS Request Bundle](http://hl7.org/fhir/us/davinci-pas/STU2.1/StructureDefinition-profile-pas-request-bundle.html)
* Examples for this Profile: [Claim/HomecareAuthorizationUpdateExample](Claim-HomecareAuthorizationUpdateExample.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.davinci-pas|current/StructureDefinition/profile-claim-update)

### Formal Views of Profile Content

 [Description Differentials, Snapshots, and other representations](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](../StructureDefinition-profile-claim-update.csv), [Excel](../StructureDefinition-profile-claim-update.xlsx), [Schematron](../StructureDefinition-profile-claim-update.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "profile-claim-update",
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
      "valueCode" : "fm"
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
      "valueInteger" : 3,
      "_valueInteger" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"
          }
        ]
      }
    },
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
      "valueCode" : "trial-use",
      "_valueCode" : {
        "extension" : [
          {
            "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
            "valueCanonical" : "http://hl7.org/fhir/us/davinci-pas/ImplementationGuide/hl7.fhir.us.davinci-pas"
          }
        ]
      }
    }
  ],
  "url" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update",
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:2.16.840.1.113883.4.642.40.24.42.48"
    }
  ],
  "version" : "2.2.0-ballot",
  "name" : "PASClaimUpdate",
  "title" : "PAS Claim Update",
  "status" : "active",
  "date" : "2026-01-30T16:26:59+00:00",
  "publisher" : "HL7 International / Financial Management",
  "contact" : [
    {
      "name" : "HL7 International / Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://hl7.org/Special/committees/fm"
        },
        {
          "system" : "email",
          "value" : "fmlists@lists.hl7.org"
        }
      ]
    },
    {
      "name" : "Jean Duteau",
      "telecom" : [
        {
          "system" : "email",
          "value" : "mailto:jean@duteaudesign.com"
        }
      ]
    },
    {
      "name" : "HL7 International / Financial Management",
      "telecom" : [
        {
          "system" : "url",
          "value" : "http://www.hl7.org/Special/committees/fm"
        }
      ]
    }
  ],
  "description" : "This profile defines constraints and extensions used when updating a previously submitted Claim instance.\n\n* The Claim instance of the update Bundle SHALL reference the updated Claim instance within the `Claim.related.claim` element. Note that the presence of this reference and the requirement that referenced instances be included in the submitted Bundle implies that the instance representing the prior version of the Claim SHALL be included in the update Bundle.\n* The Claim instance of the update Bundle SHALL contain within the `Claim.item` element each item requested in the updated claim and any prior versions of the claim, including requested items that have been added, modified, deleted, or left unchanged during this or previous updates.\n* The Claim instance of the update Bundle SHALL contain within the `Claim.supportingInfo` element each piece of supporting documentation submitted with the updated claim and any prior versions of claim, including supporting documentation that has been added, modified, deleted, or left unchanged during this or previous updates.\n* Each `Claim.item` entry that represents an item no longer being requested, whether removed in this update or a previous one, SHALL be flagged using the infoCancelledFlag modifierExtension and SHALL have the code `3` (Cancel) in the Certification Type extension.\n* Each `Claim.supportingInfo` entry that is no longer to be used when evaluating the request, whether removed in this update or a previous one, SHALL be flagged using the infoCancelledFlag modifierExtension.\n* Each `Claim.item` and `Claim.supportingInfo` entry that has been changed as a part of this most recent update, including removal, SHALL be flagged using the changed extension with a value of `changed`.\n* Each `Claim.item` and `Claim.supportingInfo` entry that has been added as a part of this most recent update, SHALL be flagged using the changed extension with a value of `added`.",
  "jurisdiction" : [
    {
      "coding" : [
        {
          "system" : "urn:iso:std:iso:3166",
          "code" : "US",
          "display" : "United States of America"
        }
      ]
    }
  ],
  "fhirVersion" : "4.0.1",
  "mapping" : [
    {
      "identity" : "workflow",
      "uri" : "http://hl7.org/fhir/workflow",
      "name" : "Workflow Pattern"
    },
    {
      "identity" : "w5",
      "uri" : "http://hl7.org/fhir/fivews",
      "name" : "FiveWs Pattern Mapping"
    },
    {
      "identity" : "rim",
      "uri" : "http://hl7.org/v3",
      "name" : "RIM Mapping"
    }
  ],
  "kind" : "resource",
  "abstract" : false,
  "type" : "Claim",
  "baseDefinition" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-base|2.2.0-ballot",
  "derivation" : "constraint",
  "differential" : {
    "element" : [
      {
        "id" : "Claim",
        "path" : "Claim"
      },
      {
        "id" : "Claim.extension:encounter",
        "path" : "Claim.extension",
        "sliceName" : "encounter",
        "short" : "Information about a hospital claim being requested.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.extension:encounter.value[x]",
        "path" : "Claim.extension.value[x]",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter|2.2.0-ballot"
            ]
          }
        ]
      },
      {
        "id" : "Claim.extension:certificationType",
        "path" : "Claim.extension",
        "sliceName" : "certificationType",
        "short" : "A code representing the type of certification being requested (UM02)",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.identifier",
        "path" : "Claim.identifier",
        "min" : 1,
        "max" : "2"
      },
      {
        "id" : "Claim.related",
        "path" : "Claim.related",
        "min" : 1,
        "max" : "1",
        "mustSupport" : true
      },
      {
        "id" : "Claim.related.claim",
        "path" : "Claim.related.claim",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "Claim.related.relationship",
        "path" : "Claim.related.relationship",
        "min" : 1,
        "patternCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship",
              "code" : "prior"
            }
          ]
        },
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo",
        "path" : "Claim.supportingInfo"
      },
      {
        "id" : "Claim.supportingInfo.extension",
        "path" : "Claim.supportingInfo.extension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        }
      },
      {
        "id" : "Claim.supportingInfo.extension:infoChanged",
        "path" : "Claim.supportingInfo.extension",
        "sliceName" : "infoChanged",
        "short" : "A code indicating how the piece of information has changed.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo.modifierExtension",
        "path" : "Claim.supportingInfo.modifierExtension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        }
      },
      {
        "id" : "Claim.supportingInfo.modifierExtension:infoCancelledFlag",
        "path" : "Claim.supportingInfo.modifierExtension",
        "sliceName" : "infoCancelledFlag",
        "short" : "Indicates that this piece of information is not to be used.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation",
        "path" : "Claim.supportingInfo",
        "sliceName" : "AdditionalInformation",
        "short" : "Send additional paperwork or supporting information for the request.  This can be most commonly a DocumentReference profile although any type of information is allowed.",
        "min" : 0,
        "max" : "*",
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation.extension",
        "path" : "Claim.supportingInfo.extension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        },
        "min" : 1
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation.extension:documentInformation",
        "path" : "Claim.supportingInfo.extension",
        "sliceName" : "documentInformation",
        "min" : 1,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-documentInformation"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation.category",
        "path" : "Claim.supportingInfo.category",
        "patternCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
              "code" : "additionalInformation"
            }
          ]
        }
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation.timing[x]",
        "path" : "Claim.supportingInfo.timing[x]",
        "max" : "0"
      },
      {
        "id" : "Claim.supportingInfo:AdditionalInformation.value[x]",
        "path" : "Claim.supportingInfo.value[x]",
        "comment" : "Although we allow of any type of information to be sent, when sending reference to documents, the US-Core DocumentReference profile SHOULD be used.",
        "min" : 1,
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-documentreference",
              "http://hl7.org/fhir/us/davinci-dtr/StructureDefinition/DTR-QRBundle",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-questionnaireresponse|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-allergyintolerance|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-encounter-diagnosis|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-condition-problems-health-concerns|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-immunization|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-procedure|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-servicerequest|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-observation-clinical-result|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-simple-observation|7.0.0",
              "http://hl7.org/fhir/us/core/StructureDefinition/us-core-vital-signs|7.0.0",
              "http://hl7.org/fhir/StructureDefinition/NutritionOrder",
              "http://hl7.org/fhir/StructureDefinition/DeviceRequest"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo:MessageText",
        "path" : "Claim.supportingInfo",
        "sliceName" : "MessageText",
        "short" : "Send text messages to the UMO.",
        "min" : 0,
        "max" : "*",
        "mustSupport" : true
      },
      {
        "id" : "Claim.supportingInfo:MessageText.category",
        "path" : "Claim.supportingInfo.category",
        "patternCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes",
              "code" : "freeFormMessage"
            }
          ]
        }
      },
      {
        "id" : "Claim.supportingInfo:MessageText.timing[x]",
        "path" : "Claim.supportingInfo.timing[x]",
        "max" : "0"
      },
      {
        "id" : "Claim.supportingInfo:MessageText.value[x]",
        "path" : "Claim.supportingInfo.value[x]",
        "min" : 1,
        "type" : [
          {
            "code" : "string"
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.diagnosis",
        "path" : "Claim.diagnosis",
        "short" : "Pertinent diagnosis information.  NOTE: Only the first 12 diagnoses can be sent in the X12 request."
      },
      {
        "id" : "Claim.diagnosis.extension",
        "path" : "Claim.diagnosis.extension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        }
      },
      {
        "id" : "Claim.diagnosis.extension:recordedDate",
        "path" : "Claim.diagnosis.extension",
        "sliceName" : "recordedDate",
        "short" : "The date that a diagnosis was recorded. (HIxx-4)",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item",
        "path" : "Claim.item",
        "min" : 1,
        "constraint" : [
          {
            "key" : "ImmediateLevelOfCare",
            "severity" : "error",
            "human" : "If Certification Type is an immediate appeal, then Level of Service Code must be present",
            "expression" : "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()",
            "source" : "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-update|2.2.0-ballot"
          }
        ]
      },
      {
        "id" : "Claim.item.extension",
        "path" : "Claim.item.extension",
        "min" : 2
      },
      {
        "id" : "Claim.item.extension:requestType",
        "path" : "Claim.item.extension",
        "sliceName" : "requestType",
        "min" : 1
      },
      {
        "id" : "Claim.item.extension:certificationType",
        "path" : "Claim.item.extension",
        "sliceName" : "certificationType",
        "min" : 1
      },
      {
        "id" : "Claim.item.extension:epsdtIndicator",
        "path" : "Claim.item.extension",
        "sliceName" : "epsdtIndicator",
        "short" : "An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.extension:nursingHomeResidentialStatus",
        "path" : "Claim.item.extension",
        "sliceName" : "nursingHomeResidentialStatus",
        "short" : "A code specifying the status of a nursing home resident at the time of service. (SV209)",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.extension:nursingHomeResidentialStatus.value[x]",
        "path" : "Claim.item.extension.value[x]",
        "mustSupport" : true,
        "binding" : {
          "strength" : "required",
          "description" : "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.",
          "valueSet" : "https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345"
        }
      },
      {
        "id" : "Claim.item.extension:nursingHomeLevelOfCare",
        "path" : "Claim.item.extension",
        "sliceName" : "nursingHomeLevelOfCare",
        "short" : "A code specifying the level of care provided by a nursing home facility. (SV120, SV210)",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.extension:revenueUnitRateLimit",
        "path" : "Claim.item.extension",
        "sliceName" : "revenueUnitRateLimit",
        "short" : "The limit on the rate per unit of revenue for hospital accomodation. (SV206)",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.extension:requestedService",
        "path" : "Claim.item.extension",
        "sliceName" : "requestedService",
        "short" : "The details of the service being requested.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.extension:infoChanged",
        "path" : "Claim.item.extension",
        "sliceName" : "infoChanged",
        "short" : "A code indicating how the piece of information has changed.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.modifierExtension",
        "path" : "Claim.item.modifierExtension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        }
      },
      {
        "id" : "Claim.item.modifierExtension:infoCancelledFlag",
        "path" : "Claim.item.modifierExtension",
        "sliceName" : "infoCancelledFlag",
        "short" : "Indicates that this piece of information is not to be used.",
        "min" : 0,
        "max" : "1",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled|2.2.0-ballot"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "Claim.item.category",
        "path" : "Claim.item.category",
        "short" : "Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request.",
        "min" : 1
      },
      {
        "id" : "Claim.item.location[x]",
        "path" : "Claim.item.location[x]",
        "min" : 1
      },
      {
        "id" : "Claim.item.unitPrice",
        "path" : "Claim.item.unitPrice",
        "mustSupport" : true
      }
    ]
  }
}

```
