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 Inquiry Response

Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse | Version: 2.2.0-ballot
Standards status: Trial-use Active as of 2026-01-30 | Maturity Level: 3 | Computable Name: PASClaimInquiryResponse
Other Identifiers: OID:2.16.840.1.113883.4.642.40.24.42.50

PAS constraints on Claim resource mandating support for elements relevant to the response of an inquiry for details of previous authorizations.

Usages:

- Use this Profile: PAS Inquiry Response Bundle and PAS Inquiry Response Bundle
- Examples for this Profile: ClaimResponse/PASClaimInquiryResponseExample

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:claimResponseReviewer | S | 0..1 | (Complex) | The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider | S | 0..* | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 0..* | PASIdentifier(2.2.0-ballot) | Business Identifier for a claim response
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 | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient(2.2.0-ballot)) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization(2.2.0-ballot)) | Party responsible for reimbursement
requestor | S | 0..1 | Reference(PAS Requestor Organization(2.2.0-ballot) | PAS PractitionerRole(2.2.0-ballot)) | Party responsible for the claim
request | S Σ | 1..1 | Reference(PAS Claim(2.2.0-ballot)) | Id of resource triggering adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:DataAbsentReason | S | 0..1 | code | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome | S Σ | 1..1 | code | complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period
item | S | 0..* | BackboneElement | Adjudication for claim line items
Slices for extension |  |  |  | Content/Rules for all slices
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | 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:requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber | S | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  |  |  | Content/Rules for all slices
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
extension:revenue | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-ballot) (required)
extension:revenueUnitRateLimit | S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request(2.2.0-ballot) | PAS Service Request(2.2.0-ballot) | PAS Device Request(2.2.0-ballot) | PAS Nutrition Order(2.2.0-ballot)) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType | S | 0..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 | 0..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:category |  | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Item sequence number
provider | S | 0..* | Reference(PAS Practitioner(2.2.0-ballot) | PAS Organization Base Profile(2.2.0-ballot)) | Authorized providers
Slices for extension |  |  |  | Content/Rules for all slices
extension:providerType | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
modifier | S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-ballot) (required)
serviced[x] | S | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] | S | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | PASQuantity(2.2.0-ballot) | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
adjudication | S | 1..* | BackboneElement | Added items adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
adjudication | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
processNote | S | 0..* | BackboneElement | Note concerning adjudication
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Note instance identifier
text | S | 1..1 | string | Note explanatory text
error | S | 0..* | BackboneElement | Processing errors
Slices for extension |  |  |  | Content/Rules for all slices
extension:followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-ballot) (required)
extension:errorElement | S | 0..1 | (Complex) | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-ballot) (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Response Outcome | 📦2.2.0-ballot | This IG
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | required | X12 278 Requested Service Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | required | X12 278 Requested Service Modifier Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | required | X12 278 Reject Reason Value Set | 📍2.2.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | ClaimResponse | 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 | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | 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()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
item |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
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:claimResponseReviewer | S | 0..1 | (Complex) | The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider | S | 0..* | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 0..* | PASIdentifier(2.2.0-ballot) | Business Identifier for a claim response
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 | More granular claim type 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 | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient(2.2.0-ballot)) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization(2.2.0-ballot)) | Party responsible for reimbursement
requestor | S | 0..1 | Reference(PAS Requestor Organization(2.2.0-ballot) | PAS PractitionerRole(2.2.0-ballot)) | Party responsible for the claim
request | S Σ | 1..1 | Reference(PAS Claim(2.2.0-ballot)) | Id of resource triggering adjudication
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:DataAbsentReason | S | 0..1 | code | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
outcome | S Σ | 1..1 | code | complete | error | partial Binding: Claim Response Outcome (required)
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item | S | 0..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | 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:requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber | S | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
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
detailSequence |  | 1..1 | positiveInt | Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
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
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem | S | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
extension:revenue | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-ballot) (required)
extension:revenueUnitRateLimit | S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request(2.2.0-ballot) | PAS Service Request(2.2.0-ballot) | PAS Device Request(2.2.0-ballot) | PAS Nutrition Order(2.2.0-ballot)) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType | S | 0..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 | 0..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:category |  | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider | S | 0..* | Reference(PAS Practitioner(2.2.0-ballot) | PAS Organization Base Profile(2.2.0-ballot)) | Authorized providers
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:providerType | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
modifier | S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-ballot) (required)
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] | S | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] | S | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | PASQuantity(2.2.0-ballot) | 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
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.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Added items adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Insurer added line details
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
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.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | 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
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
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
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.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | 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
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication | S | 0..* | BackboneElement | Header-level adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
total | Σ | 0..* | BackboneElement | Adjudication totals
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
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
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 | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote | S | 0..* | BackboneElement | Note concerning adjudication
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
number | S | 1..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text | S | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | 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 |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error | S | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-ballot) (required)
extension:errorElement | S | 0..1 | (Complex) | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-ballot) (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Response Outcome | 📦2.2.0-ballot | This IG
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​provider.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | required | X12 278 Requested Service Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | required | X12 278 Requested Service Modifier Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | required | X12 278 Reject Reason Value Set | 📍2.2.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | ClaimResponse | 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 | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | 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()`

Summary

Must-Support: 1 element

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis|2.2.0-ballot

Maturity: 3

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  |  |  | Content/Rules for all slices
extension:claimResponseReviewer | S | 0..1 | (Complex) | The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider | S | 0..* | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 0..* | PASIdentifier(2.2.0-ballot) | Business Identifier for a claim response
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 | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient(2.2.0-ballot)) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization(2.2.0-ballot)) | Party responsible for reimbursement
requestor | S | 0..1 | Reference(PAS Requestor Organization(2.2.0-ballot) | PAS PractitionerRole(2.2.0-ballot)) | Party responsible for the claim
request | S Σ | 1..1 | Reference(PAS Claim(2.2.0-ballot)) | Id of resource triggering adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:DataAbsentReason | S | 0..1 | code | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
outcome | S Σ | 1..1 | code | complete | error | partial Binding: Claim Response Outcome (required)
preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period
item | S | 0..* | BackboneElement | Adjudication for claim line items
Slices for extension |  |  |  | Content/Rules for all slices
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | 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:requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber | S | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Adjudication details
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  |  |  | Content/Rules for all slices
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
extension:revenue | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-ballot) (required)
extension:revenueUnitRateLimit | S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request(2.2.0-ballot) | PAS Service Request(2.2.0-ballot) | PAS Device Request(2.2.0-ballot) | PAS Nutrition Order(2.2.0-ballot)) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType | S | 0..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 | 0..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:category |  | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Item sequence number
provider | S | 0..* | Reference(PAS Practitioner(2.2.0-ballot) | PAS Organization Base Profile(2.2.0-ballot)) | Authorized providers
Slices for extension |  |  |  | Content/Rules for all slices
extension:providerType | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
modifier | S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-ballot) (required)
serviced[x] | S | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] | S | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | PASQuantity(2.2.0-ballot) | Count of products or services
unitPrice | S | 0..1 | Money | Fee, charge or cost per item
adjudication | S | 1..* | BackboneElement | Added items adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
adjudication | S | 0..* | BackboneElement | Header-level adjudication
Slices for extension |  |  |  | Content/Rules for all slices
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
processNote | S | 0..* | BackboneElement | Note concerning adjudication
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Note instance identifier
text | S | 1..1 | string | Note explanatory text
error | S | 0..* | BackboneElement | Processing errors
Slices for extension |  |  |  | Content/Rules for all slices
extension:followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-ballot) (required)
extension:errorElement | S | 0..1 | (Complex) | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-ballot) (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Response Outcome | 📦2.2.0-ballot | This IG
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | required | X12 278 Requested Service Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | required | X12 278 Requested Service Modifier Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | required | X12 278 Reject Reason Value Set | 📍2.2.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | ClaimResponse | 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 | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | 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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
item |  |  |  |
Slices for extension |  |  |  | Content/Rules for all slices
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
Documentation for this format

Snapshot ViewView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | PASClaimResponseBase(2.2.0-ballot) | Response to a preauthorization query
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:claimResponseReviewer | S | 0..1 | (Complex) | The responsible practitioner who reviewed to the request URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-claimResponseReviewer
extension:authorizedProvider | S | 0..* | (Complex) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 0..* | PASIdentifier(2.2.0-ballot) | Business Identifier for a claim response
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 | More granular claim type 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 | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | S Σ | 1..1 | Reference(PAS Beneficiary Patient(2.2.0-ballot)) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(PAS Insurer Organization(2.2.0-ballot)) | Party responsible for reimbursement
requestor | S | 0..1 | Reference(PAS Requestor Organization(2.2.0-ballot) | PAS PractitionerRole(2.2.0-ballot)) | Party responsible for the claim
request | S Σ | 1..1 | Reference(PAS Claim(2.2.0-ballot)) | Id of resource triggering adjudication
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:DataAbsentReason | S | 0..1 | code | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required)
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
outcome | S Σ | 1..1 | code | complete | error | partial Binding: Claim Response Outcome (required)
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item | S | 0..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | 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:requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
extension:authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
extension:authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
extension:communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12278DiagnosisCodes (2.2.0-ballot) (required)
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Sequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
noteNumber | S | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
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
detailSequence |  | 1..1 | positiveInt | Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
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
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem | S | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:itemTraceNumber | S | 0..* | PASIdentifier(2.2.0-ballot) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension:preAuthIssueDate | S | 0..1 | date | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
extension:preAuthPeriod | S | 0..1 | Period | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
extension:previousAuthorizationNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension:administrationReferenceNumber | S | 0..1 | string | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension:epsdtIndicator | S | 0..1 | boolean | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension:nursingHomeResidentialStatus | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension:nursingHomeLevelOfCare | S | 0..1 | CodeableConcept | Extension 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:productOrServiceCodeEnd | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
extension:revenue | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueCode Binding: AHANUBCRevenueCodes (2.2.0-ballot) (required)
extension:revenueUnitRateLimit | S | 0..1 | decimal | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension:requestedService | S | 0..1 | Reference(PAS Medication Request(2.2.0-ballot) | PAS Service Request(2.2.0-ballot) | PAS Device Request(2.2.0-ballot) | PAS Nutrition Order(2.2.0-ballot)) | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension:requestType | S | 0..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 | 0..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:category |  | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCategory Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider | S | 0..* | Reference(PAS Practitioner(2.2.0-ballot) | PAS Organization Base Profile(2.2.0-ballot)) | Authorized providers
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:providerType | S | 0..1 | CodeableConcept | Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedProviderType Binding: https://valueset.x12.org/x217/005010/response/2010EA/NM1/1/01/00/98 (required): Code identifying an organization entity, a physical location, property or an individual. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: X12278RequestedServiceType (2.2.0-ballot) (required)
modifier | S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: X12278RequestedServiceModifierType (2.2.0-ballot) (required)
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] | S | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] | S | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 0..1 | PASQuantity(2.2.0-ballot) | 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
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.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication | S | 1..* | BackboneElement | Added items adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Insurer added line details
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
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.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | 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
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
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
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.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | 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
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication | S | 0..* | BackboneElement | Header-level adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
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
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
total | Σ | 0..* | BackboneElement | Adjudication totals
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
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
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 | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote | S | 0..* | BackboneElement | Note concerning adjudication
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
number | S | 1..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text | S | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | 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 |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error | S | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12278FollowUpActionCodes (2.2.0-ballot) (required)
extension:errorElement | S | 0..1 | (Complex) | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
extension:errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12278RejectReasonCodes (2.2.0-ballot) (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Response Outcome | 📦2.2.0-ballot | This IG
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​provider.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | required | X12 278 Requested Service Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | required | X12 278 Requested Service Modifier Type | 📍2.2.0-ballot | This IG
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | required | X12 278 Reject Reason Value Set | 📍2.2.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | ClaimResponse | 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 | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | 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()`

Summary

Must-Support: 1 element

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis|2.2.0-ballot

Maturity: 3

Other representations of profile: CSV, Excel, Schematron