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-claimresponse | Version: 1.2.0-ballot | |||
| Active as of 2022-02-17 | Computable Name: PASClaimResponse | |||
PAS constraints on Claim resource mandating support for elements relevant to the response of a prior authorization request
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
Summary
Must-Support: 27 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..* | 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) |
| noteNumber | S | 0..* | positiveInt | Applicable note numbers |
 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 | |
| communicationRequest | S | 0..* | Reference(PAS CommunicationRequest) | Request for additional information |
| 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..* | 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 | S | 0..* | positiveInt | Applicable note numbers |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | S | 0..* | Reference(PAS 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: 27 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..* | 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) |
| noteNumber | S | 0..* | positiveInt | Applicable note numbers |
| 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 | |
| communicationRequest | S | 0..* | Reference(PAS CommunicationRequest) | Request for additional information |
| 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..* | 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 | S | 0..* | positiveInt | Applicable note numbers |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension-reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. 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 | S | 0..* | Reference(PAS 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
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