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

## Resource Profile: PAS Claim 

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

**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)
* Refer to this Profile: [PAS Claim Response Base](StructureDefinition-profile-claimresponse-base.md), [PAS Task](StructureDefinition-profile-task.md), [PAS Claim Response Base](http://hl7.org/fhir/us/davinci-pas/STU2.1/StructureDefinition-profile-claimresponse-base.html) and [PAS Task](http://hl7.org/fhir/us/davinci-pas/STU2.1/StructureDefinition-profile-task.html)
* Examples for this Profile: [Claim/HomecareAuthorizationExample](Claim-HomecareAuthorizationExample.md), [Claim/MedicalServicesAuthorizationExample](Claim-MedicalServicesAuthorizationExample.md), [Claim/ReferralAuthorizationExample](Claim-ReferralAuthorizationExample.md) and [Claim/SurgicalAuthorizationRequestExample](Claim-SurgicalAuthorizationRequestExample.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)

### 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.csv), [Excel](../StructureDefinition-profile-claim.xlsx), [Schematron](../StructureDefinition-profile-claim.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "profile-claim",
  "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",
  "identifier" : [
    {
      "system" : "urn:ietf:rfc:3986",
      "value" : "urn:oid:2.16.840.1.113883.4.642.40.24.42.49"
    }
  ],
  "version" : "2.2.0-ballot",
  "name" : "PASClaim",
  "title" : "PAS Claim",
  "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" : "PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request",
  "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.identifier",
        "path" : "Claim.identifier",
        "min" : 1,
        "max" : "2"
      },
      {
        "id" : "Claim.related",
        "path" : "Claim.related",
        "max" : "0"
      },
      {
        "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|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.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
      }
    ]
  }
}

```
