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-claimresponse-base | Version: 2.0.1 | |||
| Standards status: Trial-use | Maturity Level: 3 | Computable Name: PASClaimResponseBase | ||
PAS constraints on ClaimResponse resource that are common to both the request and the inquiry.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |
  identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
 status | S | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active |
| use | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization | |
 patient | S | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created | S | 1..1 | dateTime | Response creation date |
| insurer | S | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request | S | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period |
 item | S | 0..* | BackboneElement | Adjudication for claim line items |
  Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
 adjudication | S | 1..* | BackboneElement | Adjudication details |
 Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error | S | 0..* | BackboneElement | Processing errors |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active |
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization |
| patient | SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created | SΣ | 1..1 | dateTime | Response creation date |
| insurer | SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request | SΣ | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error | S | 0..* | BackboneElement | Processing errors |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClaimResponse.status | required | Pattern: active |
| ClaimResponse.type | extensible | ClaimTypeCodes |
| ClaimResponse.use | required | Pattern: preauthorization |
| ClaimResponse.outcome | required | ClaimProcessingCodes |
| ClaimResponse.item.adjudication.category | example | Pattern: submitted |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation | ||||
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization | ||||
| patient | SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services | ||||
| created | SΣ | 1..1 | dateTime | Response creation date | ||||
| insurer | SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement | ||||
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim | ||||
| request | SΣ | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition | 0..1 | string | Disposition Message | |||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period | ||||
| payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item | S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate | ||||
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail | ||||
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | S | 1..* | BackboneElement | Adjudication details | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount | 0..1 | Money | Monetary amount | |||||
| value | 0..1 | decimal | Non-monetary value | |||||
| detail | 0..* | BackboneElement | Adjudication for claim details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..* | positiveInt | Item sequence number | |||||
| detailSequence | 0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
 serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail | 0..* | BackboneElement | Insurer added line details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount | Σ | 1..1 | Money | Financial total for the category | ||||
| payment | 0..1 | BackboneElement | Payment Details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date | 0..1 | date | Expected date of payment | |||||
| amount | 1..1 | Money | Payable amount after adjustment | |||||
| identifier | 0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form | 0..1 | Attachment | Printed reference or actual form | |||||
| processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number | 0..1 | positiveInt | Note instance identifier | |||||
| type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text | 1..1 | string | Note explanatory text | |||||
| language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance | 0..* | BackboneElement | Patient insurance information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Insurance instance identifier | |||||
| focal | 1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage | 1..1 | Reference(Coverage) | Insurance information | |||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) | ||||
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement | ||||
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..1 | positiveInt | Item sequence number | |||||
| detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| ClaimResponse.language | preferred | CommonLanguages
| ||||
| ClaimResponse.status | required | Pattern: active | ||||
| ClaimResponse.type | extensible | ClaimTypeCodes | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodes | ||||
| ClaimResponse.use | required | Pattern: preauthorization | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodes | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codes | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submitted | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
| ClaimResponse.addItem.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodes | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodes | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodes | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codes | ||||
| ClaimResponse.formCode | example | Form Codes | ||||
| ClaimResponse.processNote.type | required | NoteType | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
| ||||
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
This structure is derived from ClaimResponse
Summary
Must-Support: 25 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Maturity: 3
Differential View
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
| status | S | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active |
| use | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization | |
| patient | S | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created | S | 1..1 | dateTime | Response creation date |
| insurer | S | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request | S | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error | S | 0..* | BackboneElement | Processing errors |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation |
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active |
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization |
| patient | SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services |
| created | SΣ | 1..1 | dateTime | Response creation date |
| insurer | SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement |
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim |
| request | SΣ | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication |
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate |
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod |
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber |
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber |
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate |
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail |
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |
| adjudication | S | 1..* | BackboneElement | Adjudication details |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
| error | S | 0..* | BackboneElement | Processing errors |
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) |
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement |
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| ClaimResponse.status | required | Pattern: active |
| ClaimResponse.type | extensible | ClaimTypeCodes |
| ClaimResponse.use | required | Pattern: preauthorization |
| ClaimResponse.outcome | required | ClaimProcessingCodes |
| ClaimResponse.item.adjudication.category | example | Pattern: submitted |
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | This is an abstract profile. Child profiles: PASClaimInquiryResponse, PASClaimResponse Response to a claim predetermination or preauthorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | S | 0..* | PASIdentifier | An identifier intended for computation | ||||
| status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization | ||||
| patient | SΣ | 1..1 | Reference(PAS Beneficiary Patient) | The recipient of the products and services | ||||
| created | SΣ | 1..1 | dateTime | Response creation date | ||||
| insurer | SΣ | 1..1 | Reference(PAS Insurer Organization) | Party responsible for reimbursement | ||||
| requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole) | Party responsible for the claim | ||||
| request | SΣ | 0..1 | Reference(PAS Claim) | Id of resource triggering adjudication | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition | 0..1 | string | Disposition Message | |||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period | ||||
| payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item | S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber | ||||
| preAuthIssueDate | S | 0..1 | date | The date when this item's preauthorization was issued. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate | ||||
| preAuthPeriod | S | 0..1 | Period | The date/period when this item's preauthorization is valid. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod | ||||
| previousAuthorizationNumber | S | 0..1 | string | A string assigned by the UMO to an authorized review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber | ||||
| administrationReferenceNumber | S | 0..1 | string | A string assigned by the UMO to the original disallowed review outcome associated with this service item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber | ||||
| requestedServiceDate | S | 0..1 | dateTime, Period | The original date/period that was requested by the submitter for this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemRequestedServiceDate | ||||
| authorizedItemDetail | S | 0..1 | (Complex) | The details of what has been authorized for this item if different from what was requested. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedDetail | ||||
| authorizedProvider | S | 0..* | (Complex) | The specific provider who has been authorized to provide this item. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemAuthorizedProvider | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | S | 1..* | BackboneElement | Adjudication details | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| reviewAction | S | 0..1 | (Complex) | The details of the review action that is necessary for the authorization. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |||||
| version | 0..1 | string | Version of the system - if relevant | |||||
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |||||
| display | 0..1 | string | Representation defined by the system | |||||
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |||||
| text | 0..1 | string | Plain text representation of the concept | |||||
| reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount | 0..1 | Money | Monetary amount | |||||
| value | 0..1 | decimal | Non-monetary value | |||||
| detail | 0..* | BackboneElement | Adjudication for claim details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..* | positiveInt | Item sequence number | |||||
| detailSequence | 0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail | 0..* | BackboneElement | Insurer added line details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount | Σ | 1..1 | Money | Financial total for the category | ||||
| payment | 0..1 | BackboneElement | Payment Details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date | 0..1 | date | Expected date of payment | |||||
| amount | 1..1 | Money | Payable amount after adjustment | |||||
| identifier | 0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form | 0..1 | Attachment | Printed reference or actual form | |||||
| processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number | 0..1 | positiveInt | Note instance identifier | |||||
| type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text | 1..1 | string | Note explanatory text | |||||
| language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance | 0..* | BackboneElement | Patient insurance information | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Insurance instance identifier | |||||
| focal | 1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage | 1..1 | Reference(Coverage) | Insurance information | |||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| followupAction | S | 0..1 | CodeableConcept | A code representing what action must occur to resolve this error. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorFollowupAction Binding: X12 278 Follow Up Action Value Set (required) | ||||
| errorElement | S | 0..1 | string | The specific X12 loop, segment, or element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorElement | ||||
| errorPath | S | 0..1 | string | The FHIRPath expression that indicates which FHIR element that this error information is about. URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-errorPath | ||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..1 | positiveInt | Item sequence number | |||||
| detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
| code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: X12 278 Reject Reason Value Set (required) | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| ClaimResponse.language | preferred | CommonLanguages
| ||||
| ClaimResponse.status | required | Pattern: active | ||||
| ClaimResponse.type | extensible | ClaimTypeCodes | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodes | ||||
| ClaimResponse.use | required | Pattern: preauthorization | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodes | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codes | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submitted | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
| ClaimResponse.addItem.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodes | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodes | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodes | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codes | ||||
| ClaimResponse.formCode | example | Form Codes | ||||
| ClaimResponse.processNote.type | required | NoteType | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
| ||||
| ClaimResponse.error.code | required | X12278RejectReasonCodes (a valid code from https://codesystem.x12.org/005010/901) |
This structure is derived from ClaimResponse
Summary
Must-Support: 25 elements
Structures
This structure refers to these other structures:
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
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change