This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.0.1: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: PAS Claim Base ( Abstract )

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

Usage:

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

Formal Views of Profile Content

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

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

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
identifier	S	0..1	PASIdentifier	Business identifier for claim
status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient		1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
insurer	S	1..1	Reference(PAS Insurer Organization)	Target
provider	S	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
value[x]		0..1	boolean	Value of extension Fixed Value: true
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
value[x]		0..1	boolean	Value of extension Fixed Value: false
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	S	1..*	BackboneElement	Patient insurance information
sequence	S	1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	S	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.location[x]	required	X12278LocationType

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..1	PASIdentifier	Business identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	SΣ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.status	required	Pattern: active
Claim.type	extensible	ClaimTypeCodes
Claim.use	required	Pattern: preauthorization
Claim.priority	example	ProcessPriorityCodes
Claim.careTeam.role	example	ClaimCareTeamRoleCodes
Claim.careTeam.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.supportingInfo:PatientEvent.category	example	Pattern: patientEvent
Claim.supportingInfo:AdmissionDates.category	example	Pattern: admissionDates
Claim.supportingInfo:DischargeDates.category	example	Pattern: dischargeDates
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.location[x]	required	X12278LocationType

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..1	PASIdentifier	Business identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis 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	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Claim.status	required	Pattern: active
Claim.type	extensible	ClaimTypeCodes
Claim.subType	example	ExampleClaimSubTypeCodes
Claim.use	required	Pattern: preauthorization
Claim.priority	example	ProcessPriorityCodes
Claim.fundsReserve	example	Funds Reservation Codes
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes
Claim.payee.type	example	Claim Payee Type Codes
Claim.careTeam.role	example	ClaimCareTeamRoleCodes
Claim.careTeam.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.supportingInfo.code	example	ExceptionCodes
Claim.supportingInfo.reason	example	MissingToothReasonCodes
Claim.supportingInfo:PatientEvent.category	example	Pattern: patientEvent
Claim.supportingInfo:PatientEvent.code	example	ExceptionCodes
Claim.supportingInfo:PatientEvent.reason	example	MissingToothReasonCodes
Claim.supportingInfo:AdmissionDates.category	example	Pattern: admissionDates
Claim.supportingInfo:AdmissionDates.code	example	ExceptionCodes
Claim.supportingInfo:AdmissionDates.reason	example	MissingToothReasonCodes
Claim.supportingInfo:DischargeDates.category	example	Pattern: dischargeDates
Claim.supportingInfo:DischargeDates.code	example	ExceptionCodes
Claim.supportingInfo:DischargeDates.reason	example	MissingToothReasonCodes
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type	example	ExampleProcedureTypeCodes
Claim.procedure.procedure[x]	example	ICD-10ProcedureCodes
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.programCode	example	ExampleProgramReasonCodes
Claim.item.location[x]	required	X12278LocationType
Claim.item.bodySite	example	OralSiteCodes
Claim.item.subSite	example	SurfaceCodes
Claim.item.detail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.category	example	BenefitCategoryCodes
Claim.item.detail.productOrService	example	USCLSCodes
Claim.item.detail.modifier	example	ModifierTypeCodes
Claim.item.detail.programCode	example	ExampleProgramReasonCodes
Claim.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.subDetail.category	example	BenefitCategoryCodes
Claim.item.detail.subDetail.productOrService	example	USCLSCodes
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

This structure is derived from Claim

Summary

Mandatory: 2 elements (9 nested mandatory elements)
Must-Support: 44 elements
Fixed Value: 2 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd

Slices

This structure defines the following Slices:

• The element Claim.careTeam is sliced based on the value of value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
• The element Claim.supportingInfo is sliced based on the value of value:category
• The element Claim.supportingInfo.timing[x] is sliced based on the value of type:$this

Maturity: 3

Differential View

This structure is derived from Claim

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
identifier	S	0..1	PASIdentifier	Business identifier for claim
status		1..1	code	active | cancelled | draft | entered-in-error Required Pattern: active
use		1..1	code	claim | preauthorization | predetermination Required Pattern: preauthorization
patient		1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
insurer	S	1..1	Reference(PAS Insurer Organization)	Target
provider	S	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
value[x]		0..1	boolean	Value of extension Fixed Value: true
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
value[x]		0..1	boolean	Value of extension Fixed Value: false
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
category		1..1	CodeableConcept	Classification of the supplied information Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1	date, Period	When it occurred Slice: Unordered, Open by type:$this
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	C	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	C	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
value[x]		0..0
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	S	1..*	BackboneElement	Patient insurance information
sequence	S	1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	S	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1	date, Period	Date or dates of service or product delivery
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.location[x]	required	X12278LocationType

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..1	PASIdentifier	Business identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Resource creation date
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	SΣ	1..*	BackboneElement	Patient insurance information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
accident	S	0..1	BackboneElement	Details of the event
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.status	required	Pattern: active
Claim.type	extensible	ClaimTypeCodes
Claim.use	required	Pattern: preauthorization
Claim.priority	example	ProcessPriorityCodes
Claim.careTeam.role	example	ClaimCareTeamRoleCodes
Claim.careTeam.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.supportingInfo:PatientEvent.category	example	Pattern: patientEvent
Claim.supportingInfo:AdmissionDates.category	example	Pattern: admissionDates
Claim.supportingInfo:DischargeDates.category	example	Pattern: dischargeDates
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.location[x]	required	X12278LocationType

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	Claim	This is an abstract profile. Child profiles: PASClaimInquiry, PASClaim Claim, Pre-determination or Pre-authorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
levelOfServiceType	S	0..1	CodeableConcept	A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
conditionCode		0..*	(Complex)	Used to indicate condition codes for various requests for service. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
homeHealthCareInformation		0..1	(Complex)	Used to provide required information about home health care services. (CR6) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	0..1	PASIdentifier	Business identifier for claim
status	?!Σ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Required Pattern: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner | PractitionerRole)	Author of the claim
insurer	SΣ	1..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization | PAS PractitionerRole)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest | MedicationRequest | VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
Slices for careTeam	S	0..*	BackboneElement	Members of the care team Slice: Unordered, Open by value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
careTeam:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Organization Base Profile | PAS PractitionerRole)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications.
careTeam:OverallClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to all services being requested. NOTE: Only the first 14 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: true
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127 (required)
careTeam:ItemClaimMember		0..*	BackboneElement	Care Team Providers that are applicable to a specific item (as referenced by that item). NOTE: Only the first 10 can be sent in the X12 Request.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
careTeamClaimScope	S	1..1	boolean	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope"
value[x]		0..1	boolean	Value of extension Fixed Value: false
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(Practitioner | PractitionerRole | Organization)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
Slices for supportingInfo	S	0..*	BackboneElement	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent		0..1	BackboneElement	Information about the dates of the event that are being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionDates		0..1	BackboneElement	Information about the admission dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:DischargeDates		0..1	BackboneElement	Information about the discharge dates of a hospital admission being requested.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: dischargeDates
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
Slices for timing[x]	S	1..1		When it occurred Slice: Unordered, Closed by type:$this
timingDate			date
timingPeriod			Period
timing[x]:timingDate	C	0..1	date	When it occurred FullDateRule: Dates need to be a full date - YYYY-MM-DD
timing[x]:timingPeriod		0..1	Period	When it occurred
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	Starting time with inclusive boundary FullDateRule: Dates need to be a full date - YYYY-MM-DD
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing FullDateRule: Dates need to be a full date - YYYY-MM-DD
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis 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	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Required Pattern: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(PAS Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
itemTraceNumber	S	0..*	PASIdentifier	Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
authorizationNumber	S	0..1	string	A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
administrationReferenceNumber	S	0..1	string	A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
requestType	S	0..1	CodeableConcept	A code that identifies the type of service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
certificationType	S	0..1	CodeableConcept	A code representing the type of certification being requested (UM02) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrServiceCodeEnd		0..1	CodeableConcept	Used to provide the last code in a series of codes for the service being requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Modifier Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Claim.status	required	Pattern: active
Claim.type	extensible	ClaimTypeCodes
Claim.subType	example	ExampleClaimSubTypeCodes
Claim.use	required	Pattern: preauthorization
Claim.priority	example	ProcessPriorityCodes
Claim.fundsReserve	example	Funds Reservation Codes
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes
Claim.payee.type	example	Claim Payee Type Codes
Claim.careTeam.role	example	ClaimCareTeamRoleCodes
Claim.careTeam.qualification	example	ExampleProviderQualificationCodes
Claim.careTeam:OverallClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98
Claim.careTeam:OverallClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127
Claim.careTeam:ItemClaimMember.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam:ItemClaimMember.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.supportingInfo.code	example	ExceptionCodes
Claim.supportingInfo.reason	example	MissingToothReasonCodes
Claim.supportingInfo:PatientEvent.category	example	Pattern: patientEvent
Claim.supportingInfo:PatientEvent.code	example	ExceptionCodes
Claim.supportingInfo:PatientEvent.reason	example	MissingToothReasonCodes
Claim.supportingInfo:AdmissionDates.category	example	Pattern: admissionDates
Claim.supportingInfo:AdmissionDates.code	example	ExceptionCodes
Claim.supportingInfo:AdmissionDates.reason	example	MissingToothReasonCodes
Claim.supportingInfo:DischargeDates.category	example	Pattern: dischargeDates
Claim.supportingInfo:DischargeDates.code	example	ExceptionCodes
Claim.supportingInfo:DischargeDates.reason	example	MissingToothReasonCodes
Claim.diagnosis.diagnosis[x]	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type	example	ExampleProcedureTypeCodes
Claim.procedure.procedure[x]	example	ICD-10ProcedureCodes
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenue	required	AHANUBCRevenueCodes (a valid code from https://www.nubc.org/revenue-code)
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceModifierType
Claim.item.programCode	example	ExampleProgramReasonCodes
Claim.item.location[x]	required	X12278LocationType
Claim.item.bodySite	example	OralSiteCodes
Claim.item.subSite	example	SurfaceCodes
Claim.item.detail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.category	example	BenefitCategoryCodes
Claim.item.detail.productOrService	example	USCLSCodes
Claim.item.detail.modifier	example	ModifierTypeCodes
Claim.item.detail.programCode	example	ExampleProgramReasonCodes
Claim.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.subDetail.category	example	BenefitCategoryCodes
Claim.item.detail.subDetail.productOrService	example	USCLSCodes
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
FullDateRule	error	Claim.supportingInfo:PatientEvent.timing[x]:timingDate, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.start, Claim.supportingInfo:PatientEvent.timing[x]:timingPeriod.end, Claim.supportingInfo:AdmissionDates.timing[x]:timingDate, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.start, Claim.supportingInfo:AdmissionDates.timing[x]:timingPeriod.end, Claim.supportingInfo:DischargeDates.timing[x]:timingDate, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.start, Claim.supportingInfo:DischargeDates.timing[x]:timingPeriod.end	Dates need to be a full date - YYYY-MM-DD : $this.toString().length() = 10

This structure is derived from Claim

Summary

Mandatory: 2 elements (9 nested mandatory elements)
Must-Support: 44 elements
Fixed Value: 2 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-conditionCode
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-homeHealthCareInformation
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
• http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd

Slices

This structure defines the following Slices:

• The element Claim.careTeam is sliced based on the value of value:extension('http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope').value as boolean
• The element Claim.supportingInfo is sliced based on the value of value:category
• The element Claim.supportingInfo.timing[x] is sliced based on the value of type:$this

Maturity: 3