Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
Da Vinci Prior Authorization Support (PAS) FHIR IG
2.0.1 - STU 2
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
| Official URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry | Version: 2.0.1 | |||
| Standards status: Trial-use | Maturity Level: 3 | Computable Name: PASClaimInquiry | ||
PAS constraints on Claim resource when submitting an inquiry for existing authorizations.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from PASClaimBase
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Claim | 0..* | PASClaimBase | Claim, Pre-determination or Pre-authorization | |
  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. |
 billablePeriod | S | 0..1 | Period | Relevant time frame for the claim |
| provider | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | This is the submitter of the inquiry. | |
| diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |
 item | ||||
 certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate |
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate |
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate |
 reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | PASClaimBase | Claim, Pre-determination or Pre-authorization | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| 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 | |
| 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. |
 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 |
| billablePeriod | SΣ | 0..1 | Period | Relevant time frame for the claim |
| 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) | This is the submitter of the inquiry. |
| 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" | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
 careTeam:ItemClaimMember | 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" | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
| Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| 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:$this | |
| timingDate | date | |||
| timingPeriod | Period | |||
| timing[x]:timingDate | C | 0..1 | date | When it occurred |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| supportingInfo:AdmissionDates | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested. | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates | |
| Slices for timing[x] | S | 1..1 | When it occurred Slice: Unordered, Closed by type:$this | |
| timingDate | date | |||
| timingPeriod | Period | |||
| timing[x]:timingDate | C | 0..1 | date | When it occurred |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| 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 |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| 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. |
| item | S | 1..* | BackboneElement | Product or service provided |
| 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) | |
| certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate |
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate |
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate |
| reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. |
| 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) |
| 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 | ||||
| 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.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.productOrService | required | X12278RequestedServiceType |
| Claim.item.modifier | required | X12278RequestedServiceModifierType |
| Claim.item.location[x] | required | X12278LocationType |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim | 0..* | PASClaimBase | 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.
| |||||
| 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 | |||||
| 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. | ||||
| 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 | SΣ | 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) | This is the submitter of the inquiry. | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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) | |||||
| certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate | ||||
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate | ||||
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate | ||||
| reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. | ||||
| 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 | ||||||||
This structure is derived from PASClaimBase
Summary
Must-Support: 6 elements
Extensions
This structure refers to these extensions:
Maturity: 3
Differential View
This structure is derived from PASClaimBase
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | PASClaimBase | Claim, Pre-determination or Pre-authorization | |
| 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. |
| billablePeriod | S | 0..1 | Period | Relevant time frame for the claim |
| provider | 1..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | This is the submitter of the inquiry. | |
| diagnosis | 0..* | BackboneElement | Pertinent diagnosis information | |
| item | ||||
| certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate |
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate |
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate |
| reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Claim | 0..* | PASClaimBase | Claim, Pre-determination or Pre-authorization | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| 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 | |
| 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. |
| 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 |
| billablePeriod | SΣ | 0..1 | Period | Relevant time frame for the claim |
| 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) | This is the submitter of the inquiry. |
| 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" | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
| careTeam:ItemClaimMember | 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" | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Order of care team | |
| provider | 1..1 | Reference(Practitioner | PractitionerRole | Organization) | Practitioner or organization | |
| Slices for supportingInfo | S | 0..* | BackboneElement | Supporting information Slice: Unordered, Open by value:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| 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:$this | |
| timingDate | date | |||
| timingPeriod | Period | |||
| timing[x]:timingDate | C | 0..1 | date | When it occurred |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| supportingInfo:AdmissionDates | 0..1 | BackboneElement | Information about the admission dates of a hospital admission being requested. | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Information instance identifier | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASTempCodes | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admissionDates | |
| Slices for timing[x] | S | 1..1 | When it occurred Slice: Unordered, Closed by type:$this | |
| timingDate | date | |||
| timingPeriod | Period | |||
| timing[x]:timingDate | C | 0..1 | date | When it occurred |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| 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 |
| timing[x]:timingPeriod | 0..1 | Period | When it occurred | |
| 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. |
| item | S | 1..* | BackboneElement | Product or service provided |
| 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) | |
| certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate |
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate |
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate |
| reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. |
| 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) |
| 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 | ||||
| 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.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.productOrService | required | X12278RequestedServiceType |
| Claim.item.modifier | required | X12278RequestedServiceModifierType |
| Claim.item.location[x] | required | X12278LocationType |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Claim | 0..* | PASClaimBase | 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.
| |||||
| 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 | |||||
| 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. | ||||
| 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 | SΣ | 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) | This is the submitter of the inquiry. | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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 | ||||
| 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 | ||||
| end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| 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) | |||||
| certIssueDate | S | 0..1 | date | The specific date or period within when which item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationIssueDate | ||||
| certExpirationDate | S | 0..1 | date | The specific date or period within which this item's preauthorization expires. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationExpirationDate | ||||
| certEffectiveDate | S | 0..1 | date | The specific date or period within which this item's preauthorization became effective. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemCertificationEffectiveDate | ||||
| reviewActionCode | S | 0..1 | CodeableConcept | The code describing the result of the review. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. 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. | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Claim.language | preferred | CommonLanguages
| ||||
| 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 |
This structure is derived from PASClaimBase
Summary
Must-Support: 6 elements
Extensions
This structure refers to these extensions:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-pas#2.0.1 based on FHIR 4.0.1. Generated 2023-12-01
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