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 Response Base ( Abstract )

PAS constraints on ClaimResponse resource that are common to both the request and the inquiry.

Usage:

• Derived from this Resource Profile: PAS Claim Inquiry Response and PAS Claim Response

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 ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
identifier	S	0..*	PASIdentifier	An identifier intended for computation
system		1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>'
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient	S	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	S	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	S	1..1	code	queued | complete | error | partial
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	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
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
itemSequence	S	1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. 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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. 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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier	An identifier intended for computation
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	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	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
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ClaimResponse.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ClaimResponse.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ClaimResponse.item.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ClaimResponse.addItem.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a 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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier	An identifier intended for computation
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	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item	S	0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product 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.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	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
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Added items adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	S	0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ClaimResponse.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ClaimResponse.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ClaimResponse.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard
ClaimResponse.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
ClaimResponse.item.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ClaimResponse.addItem.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.addItem.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

This structure is derived from ClaimResponse

Summary

Mandatory: 1 element(1 nested mandatory element)
Must-Support: 47 elements

Structures

This structure refers to these other structures:

• PAS Identifier (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-identifier)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer)
• PAS Requestor Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor)
• PAS PractitionerRole (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole)
• PAS Claim (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim)
• PAS Practitioner (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner)
• PAS Organization Base Profile (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-organization)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
• 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
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath

Maturity: 3

Differential View

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
identifier	S	0..*	PASIdentifier	An identifier intended for computation
system		1..1	uri	Should use a scheme of 'urn:trnorg:<TRN03>'
status	S	1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient	S	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	S	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	S	1..1	code	queued | complete | error | partial
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	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
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
itemSequence	S	1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. 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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. 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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier	An identifier intended for computation
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	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
item	S	0..*	BackboneElement	Adjudication for claim line items
Slices for extension		0..*	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
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
adjudication	S	1..*	BackboneElement	Added items adjudication
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
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/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
error	S	0..*	BackboneElement	Processing errors
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ClaimResponse.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ClaimResponse.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ClaimResponse.item.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ClaimResponse.addItem.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	This is an abstractprofile. Childprofiles: PASClaimInquiryResponse, PASClaimResponse Response to a 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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..*	PASIdentifier	An identifier intended for computation
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	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient	SΣ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
request	SΣ	1..1	Reference(PAS Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item	S	0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
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
requestedServiceDate	S	0..1	dateTime, Period	The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
authorizedItemDetail	S	0..1	(Complex)	The details of what has been authorized for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
authorizedProvider	S	0..*	(Complex)	The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
preAuthIssueDate	S	0..1	date	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
preAuthPeriod	S	0..1	Period	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
previousAuthorizationNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
epsdtIndicator	S	0..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
nursingHomeResidentialStatus	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
nursingHomeLevelOfCare	S	0..1	CodeableConcept	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
revenueUnitRateLimit	S	0..1	decimal	Extension 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)	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	0..*	Reference(PAS Practitioner | PAS Organization Base Profile)	Authorized providers
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Service/Product 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.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	S	0..1	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
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Added items adjudication
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
reviewAction	S	0..1	(Complex)	The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	S	0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
followupAction	S	0..1	CodeableConcept	A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required)
errorElement	S	0..1	string	The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
errorPath	S	0..1	string	The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard
ClaimResponse.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard
ClaimResponse.status	required	Pattern: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard
ClaimResponse.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard
ClaimResponse.use	required	Pattern: preauthorization http://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard
ClaimResponse.item.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ClaimResponse.addItem.productOrService	required	X12278RequestedServiceType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType from this IG
ClaimResponse.addItem.modifier	required	X12278RequestedServiceModifierType http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType from this IG
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place from the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth from the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface from the FHIR Standard
ClaimResponse.addItem.adjudication.category	example	Pattern: submitted http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.addItem.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms from the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
ClaimResponse.error.code	required	X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes from this IG

This structure is derived from ClaimResponse

Summary

Mandatory: 1 element(1 nested mandatory element)
Must-Support: 47 elements

Structures

This structure refers to these other structures:

• PAS Identifier (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-identifier)
• PAS Beneficiary Patient (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary)
• PAS Insurer Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer)
• PAS Requestor Organization (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor)
• PAS PractitionerRole (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitionerrole)
• PAS Claim (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim)
• PAS Practitioner (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner)
• PAS Organization Base Profile (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-organization)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
• 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
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath

Maturity: 3