Da Vinci Prior Authorization Support (PAS) FHIR IG
1.2.0-ballot - STU 1.2
US
Da Vinci Prior Authorization Support (PAS) FHIR IG
1.2.0-ballot - STU 1.2
US
This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.2.0-ballot: STU 1.2 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
| Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claiminquiryresponse | Version: 1.2.0-ballot | |||
| Active as of 2022-02-17 | Computable Name: PASClaimInquiryResponse | |||
PAS constraints on Claim resource mandating support for elements relevant to the response of an inquiry for details of previous authorizations.
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
Summary
Must-Support: 25 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
  identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
 status | S | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active |
| use | 1..1 | code | claim | preauthorization | predetermination Fixed Value: 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) | Party responsible for the claim |
| request | S | 0..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 | |
 extension-itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| extension-itemPreAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| extension-itemPreAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| extension-authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| extension-administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| extension-itemAuthorizedDate | S | 0..1 | dateTime, Period | The date/period by which the item that is pre-authorized must be completed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate |
| extension-itemAuthorizedDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| extension-itemAuthorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| extension-communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
 adjudication | S | 1..* | BackboneElement | Adjudication details |
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Fixed Value: As shown (Submitted Amount) | |
 coding | 1..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 | |
| extension-errorFollowupAction | 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) |
| extension-errorElement | S | 0..1 | string | The specific loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
 id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| 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 |
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: 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. Fixed Value: 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) | Party responsible for the claim |
| request | SΣ | 0..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 | |
| extension-itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| extension-itemPreAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| extension-itemPreAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| extension-authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| extension-administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| extension-itemAuthorizedDate | S | 0..1 | dateTime, Period | The date/period by which the item that is pre-authorized must be completed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate |
| extension-itemAuthorizedDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| extension-itemAuthorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| extension-communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 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 | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Fixed Value: As shown (Submitted Amount) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..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..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | 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 | 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 |
| itemSequence | 0..* | positiveInt | Item sequence number | |
| detailSequence | 0..* | positiveInt | Detail sequence number | |
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
 serviced[x] | 0..1 | Date or dates of service or product delivery | ||
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | 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 | 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 | |
| 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 | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |
| 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) Max Binding: AllLanguages: A human language. | |
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |
| insurance | 0..* | BackboneElement | Patient insurance information | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Insurance instance identifier | |
| focal | 1..1 | boolean | Coverage to be used for adjudication | |
| coverage | 1..1 | Reference(Coverage) | Insurance information | |
| businessArrangement | 0..1 | string | Additional provider contract number | |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-errorFollowupAction | 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) |
| extension-errorElement | S | 0..1 | string | The specific loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| 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 | ||||
This structure is derived from ClaimResponse
Summary
Must-Support: 25 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
| status | S | 1..1 | code | active | cancelled | draft | entered-in-error Fixed Value: active |
| use | 1..1 | code | claim | preauthorization | predetermination Fixed Value: 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) | Party responsible for the claim |
| request | S | 0..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 | |
| extension-itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| extension-itemPreAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| extension-itemPreAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| extension-authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| extension-administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| extension-itemAuthorizedDate | S | 0..1 | dateTime, Period | The date/period by which the item that is pre-authorized must be completed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate |
| extension-itemAuthorizedDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| extension-itemAuthorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| extension-communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Fixed Value: As shown (Submitted Amount) | |
| coding | 1..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 | |
| extension-errorFollowupAction | 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) |
| extension-errorElement | S | 0..1 | string | The specific loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
| id | Σ | 0..1 | string | 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) Max Binding: AllLanguages: A human language. | |
| 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 |
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: 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. Fixed Value: 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) | Party responsible for the claim |
| request | SΣ | 0..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 | |
| extension-itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| extension-itemPreAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| extension-itemPreAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| extension-authorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| extension-administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| extension-itemAuthorizedDate | S | 0..1 | dateTime, Period | The date/period by which the item that is pre-authorized must be completed. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDate |
| extension-itemAuthorizedDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| extension-itemAuthorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| extension-communicatedDiagnosis | S | 0..1 | CodeableConcept | A code representing the diagnosis that is relevant to the preauthorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-communicatedDiagnosis Binding: X12 278 Diagnosis Code Value Set (required) |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 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 | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Fixed Value: As shown (Submitted Amount) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..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..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| display | 0..0 | string | Representation defined by the system | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | 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 | 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 |
| itemSequence | 0..* | positiveInt | Item sequence number | |
| detailSequence | 0..* | positiveInt | Detail sequence number | |
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |
| serviced[x] | 0..1 | Date or dates of service or product delivery | ||
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | 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 | 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 | |
| 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 | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |
| 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) Max Binding: AllLanguages: A human language. | |
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |
| insurance | 0..* | BackboneElement | Patient insurance information | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Insurance instance identifier | |
| focal | 1..1 | boolean | Coverage to be used for adjudication | |
| coverage | 1..1 | Reference(Coverage) | Insurance information | |
| businessArrangement | 0..1 | string | Additional provider contract number | |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-errorFollowupAction | 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) |
| extension-errorElement | S | 0..1 | string | The specific loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| 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 | ||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet / Code |
| ClaimResponse.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ClaimResponse.status | required | Fixed Value: active |
| ClaimResponse.type | extensible | ClaimTypeCodes |
| ClaimResponse.subType | example | ExampleClaimSubTypeCodes |
| ClaimResponse.use | required | Fixed Value: preauthorization |
| ClaimResponse.outcome | required | ClaimProcessingCodes |
| ClaimResponse.payeeType | example | Claim Payee Type Codes |
| ClaimResponse.item.adjudication.category | example | Fixed Value: submitted |
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes |
| ClaimResponse.addItem.productOrService | example | USCLSCodes |
| ClaimResponse.addItem.modifier | example | ModifierTypeCodes |
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes |
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes |
| ClaimResponse.addItem.bodySite | example | OralSiteCodes |
| ClaimResponse.addItem.subSite | example | SurfaceCodes |
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodes |
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes |
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes |
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes |
| ClaimResponse.total.category | example | AdjudicationValueCodes |
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodes |
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes |
| ClaimResponse.fundsReserve | example | Funds Reservation Codes |
| ClaimResponse.formCode | example | Form Codes |
| ClaimResponse.processNote.type | required | NoteType |
| ClaimResponse.processNote.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ClaimResponse.error.code | required | X12278RejectReasonCodes |
IG © 2020+ HL7 International - Financial Management Work Group. Package hl7.fhir.us.davinci-pas#1.2.0-ballot based on FHIR 4.0.1. Generated 2022-02-17
Links: Table of Contents |
QA Report
| Version History |
Search |
|
Propose a change