Intersection of http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization and http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization

This is the set of resources that conform to both PDex Prior Authorization (http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization) and PDex Prior Authorization (http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-priorauthorization).

Structure

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ExplanationOfBenefit C0..*Explanation of Benefit resource
Constraints: adjudication-has-amount-type-slice
... meta Σ0..1MetaMetadata about the resource
.... extension 0..*ExtensionAdditional content defined by implementations
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: ?? (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ0..*CodingTags applied to this resource
Binding: ?? (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: ?? (preferred): A human language.
Additional BindingsPurpose
??Max Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for the resource
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: ?? (required): A code specifying the state of the resource instance.
... type SΣ1..1CodeableConceptCategory or discipline
Binding: ?? (extensible): The type or discipline-style of the claim.
... subType 0..1CodeableConceptMore granular claim type
Binding: ?? (example): A more granular claim typecode.
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: ?? (required): Complete, proposed, exploratory, other.
... patient SΣ1..1Reference(US Core Patient Profile(7.0.0))The recipient of the products and services
... billablePeriod Σ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResponse creation date
... enterer S0..1Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0))Author of the claim
... insurer SΣ1..1Reference(US Core Organization Profile(7.0.0))Party responsible for reimbursement
... provider SΣ1..1Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))Party responsible for the claim
... priority 0..1CodeableConceptDesired processing urgency
Binding: ?? (required)
... fundsReserveRequested 0..1CodeableConceptFor whom to reserve funds
Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None).
... related 0..*BackboneElementPrior or corollary claims
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... claim 0..1Reference(Claim)Reference to the related claim
.... relationship 0..1CodeableConceptHow the reference claim is related
Binding: ?? (example): Relationship of this claim to a related Claim.
.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(MedicationRequest | VisionPrescription)Prescription authorizing services or products
... originalPrescription 0..1Reference(MedicationRequest)Original prescription if superceded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptCategory of recipient
Binding: ?? (example): A code for the party to be reimbursed.
.... party 0..1Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson)Recipient reference
... referral 0..1Reference(ServiceRequest)Treatment Referral
... facility S0..1Reference(US Core Location Profile(7.0.0))Servicing Facility
... claim 0..1Reference(Claim)Claim reference
... claimResponse 0..1Reference(ClaimResponse)Claim response reference
... outcome Σ1..1codequeued | complete | error | partial
Binding: ?? (required): The result of the claim processing.
... disposition 0..1stringDisposition Message
... preAuthRef 0..*stringPreauthorization reference
... preAuthRefPeriod S0..1PeriodPreauthorization in-effect period
... careTeam 0..*BackboneElementCare Team members
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntOrder of care team
.... provider S1..1Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role 0..1CodeableConceptFunction within the team
Binding: ?? (example): The role codes for the care team members.
.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: ?? (example): Provider professional qualifications.
... supportingInfo 0..*BackboneElementSupporting information
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInformation instance identifier
.... category 1..1CodeableConceptClassification of the supplied information
Binding: ?? (example): The valuset used for additional information category codes.
.... code 0..1CodeableConceptType of information
Binding: ?? (example): The valuset used for additional information codes.
.... timing[x] 0..1When it occurred
..... timingDatedate
..... timingPeriodPeriod
.... value[x] 0..1Data to be provided
..... valueBooleanboolean
..... valueStringstring
..... valueQuantityQuantity
..... valueAttachmentAttachment
..... valueReferenceReference(Resource)
.... reason 0..1CodingExplanation for the information
Binding: ?? (example): Reason codes for the missing teeth.
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1Nature of illness or problem
Binding: ?? (example): ICD10 Diagnostic codes.
..... diagnosisCodeableConceptCodeableConcept
..... diagnosisReferenceReference(Condition)
.... type 0..*CodeableConceptTiming or nature of the diagnosis
Binding: ?? (example): The type of the diagnosis: admitting, principal, discharge.
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ?? (example): Present on admission.
.... packageCode 0..1CodeableConceptPackage billing code
Binding: ?? (example): The DRG codes associated with the diagnosis.
... procedure 0..*BackboneElementClinical procedures performed
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntProcedure instance identifier
.... type 0..*CodeableConceptCategory of Procedure
Binding: ?? (example): Example procedure type codes.
.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ?? (example): ICD10 Procedure codes.
..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... precedence 0..1positiveIntPrecedence (primary, secondary, etc.)
... insurance Σ1..*BackboneElementPatient insurance information
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... focal Σ1..1booleanCoverage to be used for adjudication
.... coverage Σ1..1Reference(HRex Member Match Coverage Profile(1.1.0))Insurance information
.... preAuthRef 0..*stringPrior authorization reference number
... accident 0..1BackboneElementDetails of the event
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date 0..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: ?? (extensible): Type of accident: work place, auto, etc.
.... location[x] 0..1Where the event occurred
..... locationAddressAddress
..... locationReferenceReference(Location)
... item 0..*BackboneElementProduct or service provided
.... extension 0..*ExtensionExtension
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable care team members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
.... category S0..1CodeableConceptBenefit classification
Binding: ?? (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..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (required)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: ?? (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..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ?? (example): Place where the service is rendered.
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1??, ??Count of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... udi 0..*Reference(Device)Unique device identifier
.... bodySite 0..1CodeableConceptAnatomical location
Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: ?? (example): The code for the tooth surface and surface combinations.
.... encounter 0..*Reference(US Core Encounter Profile(7.0.0))Encounters related to this billed item
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*BackboneElementAdjudication details
..... extension 0..*ExtensionExtension
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: ?? (required)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: ?? (example): Adjudication reason codes.
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monitary value
.... detail 0..*BackboneElementAdditional items
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntProduct or service provided
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
..... category 0..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (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..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
..... quantity 0..1??, ??Count of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... udi 0..*Reference(Device)Unique device identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*Detail level adjudication details
..... subDetail 0..*BackboneElementAdditional items
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntProduct or service provided
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ?? (example): Codes for the revenue or cost centers supplying the service and/or products.
...... category 0..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (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..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
...... quantity 0..1??, ??Count of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... udi 0..*Reference(Device)Unique device identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subDetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(US Core Practitioner Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core Organization Profile(7.0.0))Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (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..*CodeableConceptProgram the product or service is provided under
Binding: ?? (example): Program specific reason codes.
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ?? (example): Place where the service is rendered.
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1??, ??Count of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: ?? (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: ?? (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 0..*Added items adjudication
.... detail 0..*BackboneElementInsurer added line items
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (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??, ??Count of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 0..*Added items adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ?? (example): Allowable service and product codes.
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ?? (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??, ??Count of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*Added items adjudication
... adjudication S0..*BackboneElementHeader-level adjudication
.... extension 0..*ExtensionExtension
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category S1..1CodeableConceptType of adjudication information
Binding: ?? (required)
.... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: ?? (example): Adjudication reason codes.
.... amount 0..1MoneyMonetary amount
.... value 0..1decimalNon-monitary value
... total Σ0..*BackboneElementAdjudication totals
.... extension 0..*ExtensionExtension
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category SΣ1..1CodeableConceptPrior Authorization utilization codes
Binding: ?? (extensible)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 0..1CodeableConceptPartial or complete payment
Binding: ?? (example): The type (partial, complete) of the payment.
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the variance
Binding: ?? (example): Payment Adjustment reason codes.
.... date 0..1dateExpected date of payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... formCode 0..1CodeableConceptPrinted form identifier
Binding: ?? (example): The forms codes.
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: ?? (required): The presentation types of notes.
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: ?? (preferred): A human language.
Additional BindingsPurpose
??Max Binding
... benefitPeriod 0..1PeriodWhen the benefits are applicable
... benefitBalance 0..*BackboneElementBalance by Benefit Category
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category 1..1CodeableConceptBenefit classification
Binding: ?? (example): Benefit categories such as: oral, medical, vision, oral-basic etc.
.... excluded 0..1booleanExcluded from the plan
.... name 0..1stringShort name for the benefit
.... description 0..1stringDescription of the benefit or services covered
.... network 0..1CodeableConceptIn or out of network
Binding: ?? (example): Code to classify in or out of network services.
.... unit 0..1CodeableConceptIndividual or family
Binding: ?? (example): Unit covered/serviced - individual or family.
.... term 0..1CodeableConceptAnnual or lifetime
Binding: ?? (example): Coverage unit - annual, lifetime.
.... financial 0..*BackboneElementBenefit Summary
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... type 1..1CodeableConceptBenefit classification
Binding: ?? (example): Deductable, visits, co-pay, etc.
..... allowed[x] 0..1Benefits allowed
...... allowedUnsignedIntunsignedInt
...... allowedStringstring
...... allowedMoneyMoney
..... used[x] 0..1Benefits used
...... usedUnsignedIntunsignedInt
...... usedMoneyMoney

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