This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0-preview: QA Preview) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.1. For a full list of available versions, see the Directory of published versions

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Resource Profile: PAS Claim Update

PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request

Usage:

• Use this Resource Profile: PAS Request Bundle
• Examples for this Resource Profile: Claim/HomecareAuthorizationDifferentialExample and Claim/HomecareAuthorizationUpdateExample

Formal Views of Profile Content

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

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

This structure is derived from PASClaimBase

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
Slices for extension				Content/Rules for all slices
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
value[x]		1..1	Reference(PAS Encounter)	Value of extension
identifier		1..2	PASIdentifier	Business identifier for claim
related	S	1..1	BackboneElement	Prior or corollary claims
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
supportingInfo		0..*	BackboneElement	Supporting information
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
Slices for supportingInfo				Content/Rules for all slices
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
timing[x]		0..0
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
timing[x]		0..0
value[x]	S	1..1	string	Data to be provided
diagnosis		0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
item	C	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
extension		2..*	Extension	Extension
Slices for extension				Content/Rules for all slices
extension:requestType		1..1	ServiceItemRequestType	Extension
extension:certificationType		1..1	CertificationType	Extension
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
category		1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
location[x]		1..1	CodeableConcept	Place of service or where product was supplied
unitPrice	S	0..1	Money	Fee, charge or cost per item
Documentation for this format

Terminology Bindings (Differential)

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

Constraints

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

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode	S	0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation	S	0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x]		1..1	Reference(PAS Encounter)	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..2	PASIdentifier	Business identifier for claim
Slices for extension				Content/Rules for all slices
subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (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	SΣ	1..1	uri	SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
related	S	1..1	BackboneElement	Prior or corollary claims
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
careTeam:ItemClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent	S	0..1	BackboneElement	Information about the dates of the event that are being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdmissionDates	S	0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:DischargeDates	S	0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
value[x]	S	1..1	string	Data to be provided
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	SΣ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	SC	1..1	date	When the incident occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]	S	0..1	Address	Where the event occurred
item	SC	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd	S	0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
Slices for serviced[x]	S	0..1		Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate			date
servicedPeriod			Period
serviced[x]:servicedDate	C	0..1	date	Date or dates of service or product delivery FullDateRule: Dates need to be a full date - YYYY-MM-DD
serviced[x]:servicedPeriod		0..1	Period	Date or dates of service or product delivery
location[x]	S	1..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
Documentation for this format

Terminology Bindings

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

Constraints

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

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode	S	0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation	S	0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x]		1..1	Reference(PAS Encounter)	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..2	PASIdentifier	Business identifier for claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (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	SΣ	1..1	uri	SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related	S	1..1	BackboneElement	Prior or corollary claims
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
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. 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/ex-relatedclaimrelationship
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
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
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent	S	0..1	BackboneElement	Information about the dates of the event that are being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates	S	0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates	S	0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	string	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	SC	1..1	date	When the incident occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]	S	0..1	Address	Where the event occurred
item	SC	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
id		0..1	string	Unique id for inter-element referencing
Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd	S	0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x]	S	0..1		Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate			date
servicedPeriod			Period
serviced[x]:servicedDate	C	0..1	date	Date or dates of service or product delivery FullDateRule: Dates need to be a full date - YYYY-MM-DD
serviced[x]:servicedPeriod		0..1	Period	Date or dates of service or product delivery
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
location[x]	S	1..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

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

Constraints

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

This structure is derived from PASClaimBase

Summary

Mandatory: 9 elements(2 nested mandatory elements)
Must-Support: 20 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

• PAS Encounter (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter)
• US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled (Modifier)
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

Maturity: 3

Differential View

This structure is derived from PASClaimBase

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
Slices for extension				Content/Rules for all slices
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
value[x]		1..1	Reference(PAS Encounter)	Value of extension
identifier		1..2	PASIdentifier	Business identifier for claim
related	S	1..1	BackboneElement	Prior or corollary claims
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
supportingInfo		0..*	BackboneElement	Supporting information
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
Slices for supportingInfo				Content/Rules for all slices
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
timing[x]		0..0
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
timing[x]		0..0
value[x]	S	1..1	string	Data to be provided
diagnosis		0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
item	C	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
extension		2..*	Extension	Extension
Slices for extension				Content/Rules for all slices
extension:requestType		1..1	ServiceItemRequestType	Extension
extension:certificationType		1..1	CertificationType	Extension
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension		0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
category		1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request.
location[x]		1..1	CodeableConcept	Place of service or where product was supplied
unitPrice	S	0..1	Money	Fee, charge or cost per item
Documentation for this format

Terminology Bindings (Differential)

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

Constraints

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

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode	S	0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation	S	0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x]		1..1	Reference(PAS Encounter)	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..2	PASIdentifier	Business identifier for claim
Slices for extension				Content/Rules for all slices
subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (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	SΣ	1..1	uri	SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	The value that is unique Example General: 123456
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
related	S	1..1	BackboneElement	Prior or corollary claims
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
careTeam:ItemClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent	S	0..1	BackboneElement	Information about the dates of the event that are being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdmissionDates	S	0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:DischargeDates	S	0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
value[x]	S	1..1	string	Data to be provided
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	SΣ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	SC	1..1	date	When the incident occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]	S	0..1	Address	Where the event occurred
item	SC	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd	S	0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
Slices for serviced[x]	S	0..1		Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate			date
servicedPeriod			Period
serviced[x]:servicedDate	C	0..1	date	Date or dates of service or product delivery FullDateRule: Dates need to be a full date - YYYY-MM-DD
serviced[x]:servicedPeriod		0..1	Period	Date or dates of service or product delivery
location[x]	S	1..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
Documentation for this format

Terminology Bindings

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

Constraints

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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaimBase	Preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode	S	0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation	S	0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
encounter	S	0..1	(Complex)	Information about a hospital claim being requested. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter"
value[x]		1..1	Reference(PAS Encounter)	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..2	PASIdentifier	Business identifier for claim
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
subDepartment	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
jurisdiction	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierJurisdiction Binding: USPS Two Letter Alphabetic Codes (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	SΣ	1..1	uri	SHOULD use a scheme of 'urn:trnorg:<TRN03>' Example General: http://www.acme.com/identifiers/patient
value	SΣ	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	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related	S	1..1	BackboneElement	Prior or corollary claims
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
claim	S	1..1	Reference(Claim)	Reference to the related claim
relationship	S	1..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim. 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/ex-relatedclaimrelationship
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: prior
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
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value.ofType(boolean)
careTeam:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember	S	0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	(Complex)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]	S	0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent	S	0..1	BackboneElement	Information about the dates of the event that are being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates	S	0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates	S	0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category 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://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	SC	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod	S	0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	SΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation	S	0..*	BackboneElement	Send additional paperwork or supporting information for the request. This can be most commonly a DocumentReference profile although any type of information is allowed.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(US Core DocumentReference Profile(7.0.0) | Resource)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText	S	0..*	BackboneElement	Send text messages to the UMO.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible) Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	string	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information. NOTE: Only the first 12 diagnoses can be sent in the X12 request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
recordedDate	S	0..1	date	The date that a diagnosis was recorded. (HIxx-4) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	SC	1..1	date	When the incident occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]	S	0..1	Address	Where the event occurred
item	SC	1..*	BackboneElement	Product or service provided ImmediateLevelOfCare: If Certification Type is an immediate appeal, then Level of Service Code must be present
id		0..1	string	Unique id for inter-element referencing
Slices for extension		2..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	1..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd	S	0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
epsdtIndicator	S	0..1	boolean	An indicator of whether early and periodic screen for diagnosis and treatment of children is involved. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	(Complex)	A code specifying the status of a nursing home resident at the time of service. (SV209) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]	S	0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
nursingHomeLevelOfCare	S	0..1	CodeableConcept	A code specifying the level of care provided by a nursing home facility. (SV120, SV210) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	The limit on the rate per unit of revenue for hospital accomodation. (SV206) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
requestedService	S	0..1	Reference(PAS Medication Request | PAS Service Request | PAS Device Request | PAS Nutrition Order)	The details of the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
infoChanged	S	0..1	code	A code indicating how the piece of information has changed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
Slices for modifierExtension	?!Σ	0..*	Extension	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!S	0..1	InfoCancelledFlag	Indicates that this piece of information is not to be used.
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	1..1	CodeableConcept	Since PAS requests only have item-level information, a category is required for conformance with the X12 278 request. Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
Slices for serviced[x]	S	0..1		Date or dates of service or product delivery Slice: Unordered, Closed by type:$this
servicedDate			date
servicedPeriod			Period
serviced[x]:servicedDate	C	0..1	date	Date or dates of service or product delivery FullDateRule: Dates need to be a full date - YYYY-MM-DD
serviced[x]:servicedPeriod		0..1	Period	Date or dates of service or product delivery
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
location[x]	S	1..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

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

Constraints

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

This structure is derived from PASClaimBase

Summary

Mandatory: 9 elements(2 nested mandatory elements)
Must-Support: 20 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

• PAS Encounter (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter)
• US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-Claim.encounter
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/modifierextension-infoCancelled (Modifier)
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService

Maturity: 3