This page is part of the Da Vinci Payer Data Exchange (v2.0.0: STU2) 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-pdex/StructureDefinition/pdex-priorauthorization | Version: 2.0.0 | |||
Draft as of 2024-01-06 | Computable Name: PdexPriorAuthorization |
The PDex Prior Authorization (PPA) profile is based on the ExplanationOfBenefit resource and is provided to enable payers to express Prior Authorization information to members
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The PDex Prior Authorization profile has been created to enable Payers to communicate prior authorization decisions and changes to the status of a prior authorization to members.
Payers SHALL make available pending and active prior authorization decisions and related clinical documentation and forms for items and services, not including prescription drugs, including the date the prior authorization was approved, the date the authorization ends, as well as the units and services approved and those used to date, no later than one (1) business day after a provider initiates a prior authorization for the beneficiary or there is a change of status for the prior authorization.
A slice has been defined for meta.profile that makes the URI for the Structure Definition a required field. The ExplanationOfBenefit resource is used to express claims information to members in accordance with the Carin Blue Button Implementation Guide. By setting the value of ExplanationOfBenefit.Use to “preauthorization” in Prior Authorization resources a Payer will be able to exclude, or include, Prior Authorization records, dependent upon the use case. For the PDex IG it would be a case of setting “use=preauthorization” as a search parameter to include only Prior Authorization records.
[BaseURL]/ExplanationOfBenefit?use=preauthorization&patient=Patient/1
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice |
meta | ||||
Slices for profile | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this | |
profile:supportedProfile | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0 | |
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-pdex/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. |
status | S | 1..1 | code | active | cancelled | draft | entered-in-error |
type | S | 1..1 | CodeableConcept | Category or discipline |
use | S | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization |
patient | S | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services |
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim |
insurer | S | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement |
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
facility | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility |
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period |
careTeam | ||||
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization |
insurance | ||||
coverage | 1..1 | Reference(HRex Coverage Profile) | Insurance information | |
item | ||||
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 |
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 |
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |
encounter | 0..* | Reference(US Core Encounter Profile) | Encounters related to this billed item | |
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |
adjudication:All Slices | Content/Rules for all slices | |||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |
value | S | 1..1 | decimal | Non-monitary value |
addItem | ||||
provider | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Authorized providers | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | 1..1 | Money | Monetary amount | |
adjudication:denialreason | S | 0..* | Header-level adjudication | |
total | ||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization |
category | S | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) |
Documentation for this format |
Path | Conformance | ValueSet |
ExplanationOfBenefit.priority | required | ProcessPriorityCodes |
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes |
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS |
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes |
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/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. |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization |
patient | SΣ | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | Response creation date |
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim |
insurer | SΣ | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement |
provider | SΣ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
facility | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period |
careTeam | 0..* | BackboneElement | Care Team members | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(HRex Coverage Profile) | Insurance information |
item | 0..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
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 |
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 |
sequence | 1..1 | positiveInt | Item instance identifier | |
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |
encounter | 0..* | Reference(US Core Encounter Profile) | Encounters related to this billed item | |
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |
adjudication:All Slices | Content/Rules for all slices | |||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |
value | S | 1..1 | decimal | Non-monitary value |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | 1..1 | Money | Monetary amount | |
adjudication:denialreason | S | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication |
total | Σ | 0..* | BackboneElement | Adjudication totals |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SΣ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) |
amount | Σ | 1..1 | Money | Financial total for the category |
Documentation for this format |
Path | Conformance | ValueSet / Code |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus |
ExplanationOfBenefit.type | extensible | ClaimTypeCodes |
ExplanationOfBenefit.use | required | Pattern: preauthorization |
ExplanationOfBenefit.priority | required | ProcessPriorityCodes |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodes |
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes |
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS |
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunits |
ExplanationOfBenefit.item.adjudication:denialreason.category | example | Pattern: denialreason |
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes |
ExplanationOfBenefit.item.adjudication:consumedunits.category | example | Pattern: consumedunits |
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
Slices for profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this | ||||
profile:supportedProfile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0 | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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-pdex/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. | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for the resource | |||||
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 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 | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization | ||||
patient | SΣ | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim | ||||
insurer | SΣ | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement | ||||
provider | SΣ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status 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(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded 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 | 0..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 | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility | ||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period | ||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
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 | Order of care team | |||||
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | ||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
supportingInfo | 0..* | BackboneElement | Supporting 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 | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
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 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
diagnosis | 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 | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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): ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 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 | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(HRex Coverage Profile) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 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 | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
item | 0..* | 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 | ||||
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 | ||||
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 | ||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
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 | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |||||
modifier | 0..* | CodeableConcept | Product or service 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 where the service is rendered. | ||||||
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 | |||||
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(US Core Encounter Profile) | Encounters related to this billed item | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |||||
adjudication:All Slices | Content/Rules for all slices | |||||||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | S | 1..1 | Money | Monetary amount | ||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |||||
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): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | S | 1..1 | decimal | Non-monitary value | ||||
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |||||
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 | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | ||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |||||
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): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | S | 1..1 | decimal | Non-monitary value | ||||
detail | 0..* | BackboneElement | Additional 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 | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
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, medical, vision, oral-basic etc. | |||||
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 | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional 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 | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
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, medical, vision, oral-basic etc. | |||||
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 | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | 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(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | 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 where the service is rendered. | ||||||
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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
detail | 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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items 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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | ||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 1..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:denialreason | S | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | ||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | SΣ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | ||||
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 | 0..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 variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
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 | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |||||
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 | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
financial | 0..* | BackboneElement | Benefit Summary | |||||
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 | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
ExplanationOfBenefit.meta.security | extensible | All Security Labels | ||||
ExplanationOfBenefit.meta.tag | example | CommonTags | ||||
ExplanationOfBenefit.language | preferred | CommonLanguages
| ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus | ||||
ExplanationOfBenefit.type | extensible | ClaimTypeCodes | ||||
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodes | ||||
ExplanationOfBenefit.use | required | Pattern: preauthorization | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodes | ||||
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes | ||||
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodes | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codes | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodes | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodes | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodes | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodes | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codes | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodes | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCode | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes | ||||
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodes | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodes | ||||
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication | ||||
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunits | ||||
ExplanationOfBenefit.item.adjudication:allowedunits.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:denialreason.category | example | Pattern: denialreason | ||||
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes | ||||
ExplanationOfBenefit.item.adjudication:consumedunits.category | example | Pattern: consumedunits | ||||
ExplanationOfBenefit.item.adjudication:consumedunits.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator | ||||
ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication | ||||
ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodes | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
ExplanationOfBenefit.formCode | example | Form Codes | ||||
ExplanationOfBenefit.processNote.type | required | NoteType | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
| ||||
ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes | ||||
ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes | ||||
ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes | ||||
ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 0 element (7 nested mandatory elements)
Must-Support: 35 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ExplanationOfBenefit
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice |
meta | ||||
Slices for profile | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this | |
profile:supportedProfile | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0 | |
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-pdex/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. |
status | S | 1..1 | code | active | cancelled | draft | entered-in-error |
type | S | 1..1 | CodeableConcept | Category or discipline |
use | S | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization |
patient | S | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services |
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim |
insurer | S | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement |
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
facility | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility |
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period |
careTeam | ||||
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization |
insurance | ||||
coverage | 1..1 | Reference(HRex Coverage Profile) | Insurance information | |
item | ||||
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 |
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 |
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |
encounter | 0..* | Reference(US Core Encounter Profile) | Encounters related to this billed item | |
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |
adjudication:All Slices | Content/Rules for all slices | |||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication details |
category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |
value | S | 1..1 | decimal | Non-monitary value |
addItem | ||||
provider | 0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Authorized providers | |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | 1..1 | Money | Monetary amount | |
adjudication:denialreason | S | 0..* | Header-level adjudication | |
total | ||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization |
category | S | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) |
Documentation for this format |
Path | Conformance | ValueSet |
ExplanationOfBenefit.priority | required | ProcessPriorityCodes |
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes |
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS |
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes |
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
levelOfServiceType | S | 0..1 | CodeableConcept | A code specifying the level of service being requested (UM06) URL: http://hl7.org/fhir/us/davinci-pdex/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. |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. |
type | SΣ | 1..1 | CodeableConcept | Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization |
patient | SΣ | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | Response creation date |
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim |
insurer | SΣ | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement |
provider | SΣ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim |
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |
facility | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period |
careTeam | 0..* | BackboneElement | Care Team members | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence | 1..1 | positiveInt | Order of care team | |
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization |
insurance | Σ | 1..* | BackboneElement | Patient insurance information |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication |
coverage | Σ | 1..1 | Reference(HRex Coverage Profile) | Insurance information |
item | 0..* | BackboneElement | Product or service provided | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
itemTraceNumber | S | 0..* | PASIdentifier | Uniquely identifies this claim item. (2000F-TRN) URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber |
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 |
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 |
sequence | 1..1 | positiveInt | Item instance identifier | |
category | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |
encounter | 0..* | Reference(US Core Encounter Profile) | Encounters related to this billed item | |
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |
adjudication:All Slices | Content/Rules for all slices | |||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | S | 1..1 | Money | Monetary amount |
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
value | S | 1..1 | decimal | Non-monitary value |
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
reason | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) |
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication details |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |
value | S | 1..1 | decimal | Non-monitary value |
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category |
adjudication:All Slices | Content/Rules for all slices | |||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) |
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level adjudication |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |
amount | 1..1 | Money | Monetary amount | |
adjudication:denialreason | S | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication |
total | Σ | 0..* | BackboneElement | Adjudication totals |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | SΣ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) |
amount | Σ | 1..1 | Money | Financial total for the category |
Documentation for this format |
Path | Conformance | ValueSet / Code |
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus |
ExplanationOfBenefit.type | extensible | ClaimTypeCodes |
ExplanationOfBenefit.use | required | Pattern: preauthorization |
ExplanationOfBenefit.priority | required | ProcessPriorityCodes |
ExplanationOfBenefit.outcome | required | ClaimProcessingCodes |
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes |
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS |
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunits |
ExplanationOfBenefit.item.adjudication:denialreason.category | example | Pattern: denialreason |
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes |
ExplanationOfBenefit.item.adjudication:consumedunits.category | example | Pattern: consumedunits |
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator |
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication |
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ExplanationOfBenefit | C | 0..* | ExplanationOfBenefit | Explanation of Benefit resource adjudication-has-amount-type-slice: If Adjudication is present, it must have at least one adjudicationamounttype slice | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
Slices for profile | Σ | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to Slice: Unordered, Open by pattern:$this | ||||
profile:supportedProfile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization|2.0.0 | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
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-pdex/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. | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for the resource | |||||
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ExplanationOfBenefitStatus (required): A code specifying the state of the resource instance. | ||||
type | SΣ | 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 | SΣ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Complete, proposed, exploratory, other. Required Pattern: preauthorization | ||||
patient | SΣ | 1..1 | Reference(US Core Patient Profile) | The recipient of the products and services | ||||
billablePeriod | Σ | 0..1 | Period | Relevant time frame for the claim | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
enterer | S | 0..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | Author of the claim | ||||
insurer | SΣ | 1..1 | Reference(US Core Organization Profile) | Party responsible for reimbursement | ||||
provider | SΣ | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Party responsible for the claim | ||||
priority | 0..1 | CodeableConcept | Desired processing urgency Binding: ProcessPriorityCodes (required) | |||||
fundsReserveRequested | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status 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(MedicationRequest | VisionPrescription) | Prescription authorizing services or products | |||||
originalPrescription | 0..1 | Reference(MedicationRequest) | Original prescription if superceded 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 | 0..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 | S | 0..1 | Reference(US Core Location Profile) | Servicing Facility | ||||
claim | 0..1 | Reference(Claim) | Claim reference | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Claim response reference | |||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..* | string | Preauthorization reference | |||||
preAuthRefPeriod | S | 0..1 | Period | Preauthorization in-effect period | ||||
careTeam | 0..* | BackboneElement | Care Team members | |||||
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 | Order of care team | |||||
provider | S | 1..1 | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | Practitioner or organization | ||||
responsible | 0..1 | boolean | Indicator of the lead practitioner | |||||
role | 0..1 | CodeableConcept | Function within the team Binding: ClaimCareTeamRoleCodes (example): The role codes for the care team members. | |||||
qualification | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example): Provider professional qualifications. | |||||
supportingInfo | 0..* | BackboneElement | Supporting 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 | Information instance identifier | |||||
category | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. | |||||
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 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth. | |||||
diagnosis | 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 | 1..1 | positiveInt | Diagnosis instance identifier | |||||
diagnosis[x] | 1..1 | Nature of illness or problem Binding: ICD-10Codes (example): ICD10 Diagnostic codes. | ||||||
diagnosisCodeableConcept | CodeableConcept | |||||||
diagnosisReference | Reference(Condition) | |||||||
type | 0..* | CodeableConcept | Timing or nature of the diagnosis Binding: ExampleDiagnosisTypeCodes (example): The type of the diagnosis: admitting, principal, discharge. | |||||
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): ICD10 Procedure codes. | ||||||
procedureCodeableConcept | CodeableConcept | |||||||
procedureReference | Reference(Procedure) | |||||||
udi | 0..* | Reference(Device) | Unique device identifier | |||||
precedence | 0..1 | positiveInt | Precedence (primary, secondary, etc.) | |||||
insurance | Σ | 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 | ||||
focal | Σ | 1..1 | boolean | Coverage to be used for adjudication | ||||
coverage | Σ | 1..1 | Reference(HRex Coverage Profile) | Insurance information | ||||
preAuthRef | 0..* | string | Prior authorization reference number | |||||
accident | 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 | 0..1 | date | When the incident occurred | |||||
type | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible): Type of accident: work place, auto, etc. | |||||
location[x] | 0..1 | Where the event occurred | ||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
item | 0..* | 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 | ||||
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 | ||||
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 | ||||
sequence | 1..1 | positiveInt | Item instance identifier | |||||
careTeamSequence | 0..* | positiveInt | Applicable care team members | |||||
diagnosisSequence | 0..* | positiveInt | Applicable diagnoses | |||||
procedureSequence | 0..* | positiveInt | Applicable procedures | |||||
informationSequence | 0..* | positiveInt | Applicable exception and supporting information | |||||
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 | S | 0..1 | CodeableConcept | Benefit classification Binding: Prior Authorization Service Type Codes (X12) (required): Codes identifying business groupings for health care services or benefits. 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 | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: Prior Authorization Procedure Codes - AMA CPT - CMS HCPCS - CMS HIPPS (required) | |||||
modifier | 0..* | CodeableConcept | Product or service 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 where the service is rendered. | ||||||
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 | |||||
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(US Core Encounter Profile) | Encounters related to this billed item | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
Slices for adjudication | 0..* | BackboneElement | Adjudication details Slice: Unordered, Closed by pattern:category | |||||
adjudication:All Slices | Content/Rules for all slices | |||||||
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 at the line level. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | S | 1..1 | Money | Monetary amount | ||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:allowedunits | S | 0..1 | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |||||
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): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | S | 1..1 | decimal | Non-monitary value | ||||
adjudication:denialreason | S | 0..* | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |||||
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 | S | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: X12 Claim Adjustment Reason Codes - Remittance Advice Remark Codes (required) | ||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:consumedunits | S | 0..1 | BackboneElement | Adjudication 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information 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://hl7.org/fhir/us/davinci-pdex/CodeSystem/PDexAdjudicationDiscriminator | |||||
version | 0..1 | string | Version of the system - if relevant | |||||
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: consumedunits | |||||
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): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | S | 1..1 | decimal | Non-monitary value | ||||
detail | 0..* | BackboneElement | Additional 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 | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
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, medical, vision, oral-basic etc. | |||||
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 | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Additional 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 | ||||
sequence | 1..1 | positiveInt | Product or service provided | |||||
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, medical, vision, oral-basic etc. | |||||
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 | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
adjudication | 0..* | See adjudication (ExplanationOfBenefit) | 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(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) | 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 where the service is rendered. | ||||||
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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
detail | 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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items 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 | 0..* | See adjudication (ExplanationOfBenefit) | Added items adjudication | |||||
Slices for adjudication | S | 0..* | BackboneElement | Header-level adjudication Slice: Unordered, Closed by pattern:category | ||||
adjudication:All Slices | Content/Rules for all slices | |||||||
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 for the entire request. URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/extension-reviewAction | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | S | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication Category Discriminator (required) | ||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 0..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:adjudicationamounttype | S | 0..* | BackboneElement | Header-level 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 | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: PDex Adjudication (required) | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): Adjudication reason codes. | |||||
amount | 1..1 | Money | Monetary amount | |||||
value | 0..1 | decimal | Non-monitary value | |||||
adjudication:denialreason | S | 0..* | See adjudication (ExplanationOfBenefit) | Header-level adjudication | ||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
priorauth-utilization | S | 0..1 | Quantity, Ratio | An attribute to express the amount of a service or item that has been utilized URL: http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/PriorAuthorizationUtilization | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | SΣ | 1..1 | CodeableConcept | Prior Authorization utilization codes Binding: Prior Authorization value categories (extensible) | ||||
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 | 0..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 variance Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 0..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
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 | 0..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
benefitPeriod | 0..1 | Period | When the benefits are applicable | |||||
benefitBalance | 0..* | BackboneElement | Balance by Benefit Category | |||||
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 | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral, medical, vision, oral-basic etc. | |||||
excluded | 0..1 | boolean | Excluded from the plan | |||||
name | 0..1 | string | Short name for the benefit | |||||
description | 0..1 | string | Description of the benefit or services covered | |||||
network | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example): Code to classify in or out of network services. | |||||
unit | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example): Unit covered/serviced - individual or family. | |||||
term | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example): Coverage unit - annual, lifetime. | |||||
financial | 0..* | BackboneElement | Benefit Summary | |||||
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 | Benefit classification Binding: BenefitTypeCodes (example): Deductable, visits, co-pay, etc. | |||||
allowed[x] | 0..1 | Benefits allowed | ||||||
allowedUnsignedInt | unsignedInt | |||||||
allowedString | string | |||||||
allowedMoney | Money | |||||||
used[x] | 0..1 | Benefits used | ||||||
usedUnsignedInt | unsignedInt | |||||||
usedMoney | Money | |||||||
Documentation for this format |
Path | Conformance | ValueSet / Code | ||||
ExplanationOfBenefit.meta.security | extensible | All Security Labels | ||||
ExplanationOfBenefit.meta.tag | example | CommonTags | ||||
ExplanationOfBenefit.language | preferred | CommonLanguages
| ||||
ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus | ||||
ExplanationOfBenefit.type | extensible | ClaimTypeCodes | ||||
ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodes | ||||
ExplanationOfBenefit.use | required | Pattern: preauthorization | ||||
ExplanationOfBenefit.priority | required | ProcessPriorityCodes | ||||
ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes | ||||
ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes | ||||
ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodes | ||||
ExplanationOfBenefit.payee.type | example | Claim Payee Type Codes | ||||
ExplanationOfBenefit.outcome | required | ClaimProcessingCodes | ||||
ExplanationOfBenefit.careTeam.role | example | ClaimCareTeamRoleCodes | ||||
ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodes | ||||
ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodes | ||||
ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes | ||||
ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes | ||||
ExplanationOfBenefit.diagnosis.diagnosis[x] | example | ICD-10Codes | ||||
ExplanationOfBenefit.diagnosis.type | example | ExampleDiagnosisTypeCodes | ||||
ExplanationOfBenefit.diagnosis.onAdmission | example | ExampleDiagnosisOnAdmissionCodes | ||||
ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes | ||||
ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes | ||||
ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes | ||||
ExplanationOfBenefit.accident.type | extensible | ActIncidentCode | ||||
ExplanationOfBenefit.item.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.category | required | PriorAuthServiceTypeCodes | ||||
ExplanationOfBenefit.item.productOrService | required | PDexPAInstitutionalProcedureCodesVS | ||||
ExplanationOfBenefit.item.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes | ||||
ExplanationOfBenefit.item.bodySite | example | OralSiteCodes | ||||
ExplanationOfBenefit.item.subSite | example | SurfaceCodes | ||||
ExplanationOfBenefit.item.adjudication.category | required | PDexAdjudicationCategoryDiscriminator | ||||
ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | PDexAdjudication | ||||
ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:allowedunits.category | example | Pattern: allowedunits | ||||
ExplanationOfBenefit.item.adjudication:allowedunits.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.adjudication:denialreason.category | example | Pattern: denialreason | ||||
ExplanationOfBenefit.item.adjudication:denialreason.reason | required | X12ClaimAdjustmentReasonCodesCMSRemittanceAdviceRemarkCodes | ||||
ExplanationOfBenefit.item.adjudication:consumedunits.category | example | Pattern: consumedunits | ||||
ExplanationOfBenefit.item.adjudication:consumedunits.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes | ||||
ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes | ||||
ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes | ||||
ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes | ||||
ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
ExplanationOfBenefit.adjudication.category | required | PDexAdjudicationCategoryDiscriminator | ||||
ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | PDexAdjudication | ||||
ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes | ||||
ExplanationOfBenefit.total.category | extensible | PriorAuthorizationAmounts (a valid code from Prior Authorization Values) | ||||
ExplanationOfBenefit.payment.type | example | ExamplePaymentTypeCodes | ||||
ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
ExplanationOfBenefit.formCode | example | Form Codes | ||||
ExplanationOfBenefit.processNote.type | required | NoteType | ||||
ExplanationOfBenefit.processNote.language | preferred | CommonLanguages
| ||||
ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes | ||||
ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes | ||||
ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes | ||||
ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes | ||||
ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes |
Id | Grade | Path(s) | Details | Requirements |
adjudication-has-amount-type-slice | warning | ExplanationOfBenefit | If Adjudication is present, it must have at least one adjudicationamounttype slice : (adjudication.exists().not() or adjudication.where(category.memberOf('http://hl7.org/fhir/us/davinc-pdex/ValueSet/PDEXAdjudication')).exists()) |
This structure is derived from ExplanationOfBenefit
Summary
Mandatory: 0 element (7 nested mandatory elements)
Must-Support: 35 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron