Da Vinci Prior Authorization Support (PAS) FHIR IG
1.0.0 - STU 1

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: PAS Claim Inquiry

Defining URL:http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry
Version:1.0.0
Name:PASClaimInquiry
Title:PAS Claim Inquiry
Status:Active as of 2020-12-20T19:17:24+00:00
Definition:

PAS constraints on Claim resource when submitting an inquiry for existing authorizations.

Publisher:HL7 International - Financial Management Work Group
Source Resource:XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim-inquiry

Formal Views of Profile Content

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

This structure is derived from Claim

Summary

Mandatory: 2 elements (3 nested mandatory elements)
Must-Support: 45 elements
Fixed Value: 2 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Claim.supportingInfo is sliced based on the value of value:category
  • The element Claim.diagnosis.diagnosis[x] is sliced based on the value of type:$this
  • The element Claim.item.location[x] is sliced based on the value of type:$this

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-certificationType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... extension-levelOfServiceCode S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... use 1..1codeclaim | preauthorization | predetermination
Fixed Value: preauthorization
... patient 1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod S0..1PeriodRelevant time frame for the claim
... insurer S0..1Reference(PAS Insurer Organization)Target
... provider S1..1Reference(PAS Requestor Organization)Party responsible for the claim
... careTeam S0..*BackboneElementMembers of the care team
.... sequence S1..1positiveIntOrder of care team
.... provider S1..1Reference(PAS Practitioner | US Core Organization Profile)Practitioner or organization
.... role S0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... supportingInfo S0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
.... supportingInfo:PatientEvent 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
..... timing[x] S1..1date, PeriodWhen it occurred
..... value[x] 0..0
.... supportingInfo:AdmissionReview 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionReview
..... timing[x] S1..1date, PeriodWhen it occurred
..... value[x] 0..0
... diagnosis S0..*BackboneElementPertinent diagnosis information
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1(Slice Definition)Nature of illness or problem
Slice: Unordered, Open by type:$this
.... diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
... insurance S1..*BackboneElementPatient insurance information
.... sequence S1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... coverage S1..1Reference(Coverage)Insurance information
... accident S0..1BackboneElementDetails of the event
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemTraceNumber S0..1IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... extension-authorizationNumber S0..1stringExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... extension-administrationReferenceNumber S0..1stringExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... extension-itemPreAuthIssueDate S0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... extension-itemPreAuthPeriod S0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-serviceItemRequestType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-certificationType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-reviewActionCode S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-productOrServiceCodeEnd 0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Type (required)
.... serviced[x] S0..1date, PeriodDate or dates of service or product delivery
.... location[x] S0..1(Slice Definition)Place of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-certificationType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... extension-levelOfServiceCode S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Fixed Value: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod SΣ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ0..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... 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: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (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 0..1Reference(Location)Servicing facility
... careTeam S0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntOrder of care team
.... provider S1..1Reference(PAS Practitioner | US Core Organization Profile)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... supportingInfo S0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (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..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:PatientEvent 0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:AdmissionReview 0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionReview
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1(Slice Definition)Nature of illness or problem
Slice: Unordered, Closed by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosis[x]:diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... 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: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance SΣ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage SΣ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident S0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemTraceNumber S0..1IdentifierOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... extension-authorizationNumber S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... extension-administrationReferenceNumber S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... extension-itemPreAuthIssueDate S0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... extension-itemPreAuthPeriod S0..1PeriodOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-serviceItemRequestType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-certificationType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-reviewActionCode S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-productOrServiceCodeEnd 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Type (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1(Slice Definition)Place of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... location[x]:locationCodeableConcept 0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount 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: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount 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
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount 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
... total 0..1MoneyTotal claim cost

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... extension-certificationType 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... extension-levelOfServiceCode 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... identifier 1..1IdentifierBusiness Identifier for claim
... insurer Σ0..1Reference(PAS Insurer Organization)Target
... provider Σ1..1Reference(PAS Requestor Organization)Party responsible for the claim
... careTeam 0..*BackboneElementMembers of the care team
.... sequence 1..1positiveIntOrder of care team
.... provider 1..1Reference(PAS Practitioner | US Core Organization Profile)Practitioner or organization
.... role 0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... qualification 0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... supportingInfo 0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... sequence 1..1positiveIntInformation instance identifier
..... category 1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
.... supportingInfo:PatientEvent 0..1BackboneElementSupporting information
..... timing[x] 1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
.... supportingInfo:AdmissionReview 0..1BackboneElementSupporting information
..... timing[x] 1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... sequence 1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] 1..1(Slice Definition)Nature of illness or problem
Slice: Unordered, Closed by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

.... type 0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
... insurance Σ1..*BackboneElementPatient insurance information
.... sequence Σ1..1positiveIntInsurance instance identifier
.... coverage Σ1..1Reference(Coverage)Insurance information
... accident 0..1BackboneElementDetails of the event
.... date 1..1dateWhen the incident occurred
.... type 0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... item 1..*BackboneElementProduct or service provided
.... extension-itemTraceNumber 0..1IdentifierOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... extension-authorizationNumber 0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... extension-administrationReferenceNumber 0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... extension-itemPreAuthIssueDate 0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... extension-itemPreAuthPeriod 0..1PeriodOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-serviceItemRequestType 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-certificationType 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-reviewActionCode 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... sequence 1..1positiveIntItem instance identifier
.... careTeamSequence 0..*positiveIntApplicable careTeam members
.... diagnosisSequence 0..*positiveIntApplicable diagnoses
.... informationSequence 0..*positiveIntApplicable exception and supporting information
.... revenue 0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier 0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Type (required)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1(Slice Definition)Place of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

.... quantity 0..1SimpleQuantityCount of products or services

doco Documentation for this format

This structure is derived from Claim

Summary

Mandatory: 2 elements (3 nested mandatory elements)
Must-Support: 45 elements
Fixed Value: 2 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element Claim.supportingInfo is sliced based on the value of value:category
  • The element Claim.diagnosis.diagnosis[x] is sliced based on the value of type:$this
  • The element Claim.item.location[x] is sliced based on the value of type:$this

Differential View

This structure is derived from Claim

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-certificationType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... extension-levelOfServiceCode S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

... use 1..1codeclaim | preauthorization | predetermination
Fixed Value: preauthorization
... patient 1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod S0..1PeriodRelevant time frame for the claim
... insurer S0..1Reference(PAS Insurer Organization)Target
... provider S1..1Reference(PAS Requestor Organization)Party responsible for the claim
... careTeam S0..*BackboneElementMembers of the care team
.... sequence S1..1positiveIntOrder of care team
.... provider S1..1Reference(PAS Practitioner | US Core Organization Profile)Practitioner or organization
.... role S0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... supportingInfo S0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
.... supportingInfo:PatientEvent 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
..... timing[x] S1..1date, PeriodWhen it occurred
..... value[x] 0..0
.... supportingInfo:AdmissionReview 0..1BackboneElementSupporting information
..... category 1..1CodeableConceptClassification of the supplied information
Required Pattern: At least the following
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionReview
..... timing[x] S1..1date, PeriodWhen it occurred
..... value[x] 0..0
... diagnosis S0..*BackboneElementPertinent diagnosis information
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1(Slice Definition)Nature of illness or problem
Slice: Unordered, Open by type:$this
.... diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
... insurance S1..*BackboneElementPatient insurance information
.... sequence S1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... coverage S1..1Reference(Coverage)Insurance information
... accident S0..1BackboneElementDetails of the event
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemTraceNumber S0..1IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... extension-authorizationNumber S0..1stringExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... extension-administrationReferenceNumber S0..1stringExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... extension-itemPreAuthIssueDate S0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... extension-itemPreAuthPeriod S0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-serviceItemRequestType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-certificationType S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-reviewActionCode S0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... extension-productOrServiceCodeEnd 0..1CodeableConceptExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Type (required)
.... serviced[x] S0..1date, PeriodDate or dates of service or product delivery
.... location[x] S0..1(Slice Definition)Place of service or where product was supplied
Slice: Unordered, Open by type:$this
.... locationCodeableConcept 0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount of products or services

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*ClaimClaim, Pre-determination or Pre-authorization
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-certificationType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... extension-levelOfServiceCode S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/06/00/1338 (required): Codes specifying the level of service rendered. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S1..1IdentifierBusiness Identifier for claim
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptCategory or discipline
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim.


Fixed Value: preauthorization
... patient Σ1..1Reference(PAS Beneficiary Patient)The recipient of the products and services
... billablePeriod SΣ0..1PeriodRelevant time frame for the claim
... created Σ1..1dateTimeResource creation date
... enterer 0..1Reference(Practitioner | PractitionerRole)Author of the claim
... insurer SΣ0..1Reference(PAS Insurer Organization)Target
... provider SΣ1..1Reference(PAS Requestor Organization)Party responsible for the claim
... priority Σ1..1CodeableConceptDesired processing ugency
Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.

... fundsReserve 0..1CodeableConceptFor whom to reserve funds
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... related 0..*BackboneElementPrior or corollary claims
.... id 0..1stringUnique id for inter-element referencing
.... 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: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.

.... reference 0..1IdentifierFile or case reference
... prescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Prescription authorizing services and products
... originalPrescription 0..1Reference(DeviceRequest | MedicationRequest | VisionPrescription)Original prescription if superseded by fulfiller
... payee 0..1BackboneElementRecipient of benefits payable
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptCategory of recipient
Binding: Claim Payee Type Codes (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 0..1Reference(Location)Servicing facility
... careTeam S0..*BackboneElementMembers of the care team
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntOrder of care team
.... provider S1..1Reference(PAS Practitioner | US Core Organization Profile)Practitioner or organization
.... responsible 0..1booleanIndicator of the lead practitioner
.... role S0..1CodeableConceptFunction within the team
Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... qualification S0..1CodeableConceptPractitioner credential or specialization
Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
... supportingInfo S0..*(Slice Definition)Supporting information
Slice: Unordered, Open by value:category
.... supportingInfo:All Slices Content/Rules for all slices
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence S1..1positiveIntInformation instance identifier
..... category S1..1CodeableConceptClassification of the supplied information
Binding: PAS Supporting Info Type Value Set (extensible)
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (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..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:PatientEvent 0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: patientEvent
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:AdmissionReview 0..1BackboneElementSupporting information
..... id 0..1stringUnique id for inter-element referencing
..... 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: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes.


Required Pattern: At least the following
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
....... id0..1stringUnique id for inter-element referencing
....... extension0..*ExtensionAdditional content defined by implementations
....... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
....... version0..1stringVersion of the system - if relevant
....... code1..1codeSymbol in syntax defined by the system
Fixed Value: admissionReview
....... display0..1stringRepresentation defined by the system
....... userSelected0..1booleanIf this coding was chosen directly by the user
...... text0..1stringPlain text representation of the concept
..... code 0..1CodeableConceptType of information
Binding: ExceptionCodes (example): The valuset used for additional information codes.

..... timing[x] S1..1When it occurred
...... timingDatedate
...... timingPeriodPeriod
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

... diagnosis S0..*BackboneElementPertinent diagnosis information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntDiagnosis instance identifier
.... diagnosis[x] S1..1(Slice Definition)Nature of illness or problem
Slice: Unordered, Closed by type:$this
Binding: ICD-10Codes (example): Example ICD10 Diagnostic codes.

..... diagnosis[x]:diagnosisCodeableConcept 1..1CodeableConceptNature of illness or problem
Binding: X12 278 Diagnosis Code Value Set (required)
.... type S0..1CodeableConceptTiming or nature of the diagnosis
Binding: X12 278 Diagnosis Type Value Set (required)
.... onAdmission 0..1CodeableConceptPresent on admission
Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.

.... packageCode 0..1CodeableConceptPackage billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.

... procedure 0..*BackboneElementClinical procedures performed
.... id 0..1stringUnique id for inter-element referencing
.... 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: ExampleProcedureTypeCodes (example): Example procedure type codes.


.... date 0..1dateTimeWhen the procedure was performed
.... procedure[x] 1..1Specific clinical procedure
Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.

..... procedureCodeableConceptCodeableConcept
..... procedureReferenceReference(Procedure)
.... udi 0..*Reference(Device)Unique device identifier
... insurance SΣ1..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence SΣ1..1positiveIntInsurance instance identifier
.... focal Σ1..1booleanCoverage to be used for adjudication
Fixed Value: true
.... identifier 0..1IdentifierPre-assigned Claim number
.... coverage SΣ1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... preAuthRef 0..*stringPrior authorization reference number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... accident S0..1BackboneElementDetails of the event
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... date S1..1dateWhen the incident occurred
.... type S0..1CodeableConceptThe nature of the accident
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... location[x] 0..1AddressWhere the event occurred
... item S1..*BackboneElementProduct or service provided
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemTraceNumber S0..1IdentifierOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
.... extension-authorizationNumber S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
.... extension-administrationReferenceNumber S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
.... extension-itemPreAuthIssueDate S0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... extension-itemPreAuthPeriod S0..1PeriodOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-serviceItemRequestType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType
Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/01/00/1525 (required): Codes indicating a type of request. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-certificationType S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/02/00/1322 (required): Codes indicating the type of certification. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-reviewActionCode S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
Binding: https://valueset.x12.org/x217/005010/response/2000F/HCR/1/01/00/306 (required): Codes indicating type of action. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.


.... extension-productOrServiceCodeEnd 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntItem instance identifier
.... careTeamSequence S0..*positiveIntApplicable careTeam members
.... diagnosisSequence S0..*positiveIntApplicable diagnoses
.... procedureSequence 0..*positiveIntApplicable procedures
.... informationSequence S0..*positiveIntApplicable exception and supporting information
.... revenue S0..1CodeableConceptRevenue or cost center code
Binding: AHA NUBC Revenue Value Set (required)
.... category 0..1CodeableConceptBenefit classification
Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.

.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: X12 278 Requested Service Type (required)
.... modifier S0..*CodeableConceptProduct or service billing modifiers
Binding: X12 278 Requested Service Type (required)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] S0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1(Slice Definition)Place of service or where product was supplied
Slice: Unordered, Closed by type:$this
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... location[x]:locationCodeableConcept 0..1CodeableConceptPlace of service or where product was supplied
Binding: X12 278 Health Care Service Location Type Value Set (required)
.... quantity S0..1SimpleQuantityCount 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: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... encounter 0..*Reference(Encounter)Encounters related to this billed item
.... detail 0..*BackboneElementProduct or service provided
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... sequence 1..1positiveIntItem instance identifier
..... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

..... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


..... quantity 0..1SimpleQuantityCount 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
..... subDetail 0..*BackboneElementProduct or service provided
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... sequence 1..1positiveIntItem instance identifier
...... revenue 0..1CodeableConceptRevenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.

...... category 0..1CodeableConceptBenefit classification
Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.

...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


...... quantity 0..1SimpleQuantityCount 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
... total 0..1MoneyTotal claim cost

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
Claim.languagepreferredCommonLanguages
Max Binding: AllLanguages
Claim.statusrequiredFinancialResourceStatusCodes
Claim.typeextensibleClaimTypeCodes
Claim.subTypeexampleExampleClaimSubTypeCodes
Claim.userequiredFixed Value: preauthorization
Claim.priorityexampleProcessPriorityCodes
Claim.fundsReserveexampleFunds Reservation Codes
Claim.related.relationshipexampleExampleRelatedClaimRelationshipCodes
Claim.payee.typeexampleClaim Payee Type Codes
Claim.careTeam.rolerequiredhttps://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam.qualificationrequiredhttps://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.categoryextensiblePASSupportingInfoType
Claim.supportingInfo.codeexampleExceptionCodes
Claim.supportingInfo.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:PatientEvent.categoryexamplePattern: patientEvent
Claim.supportingInfo:PatientEvent.codeexampleExceptionCodes
Claim.supportingInfo:PatientEvent.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:AdmissionReview.categoryexamplePattern: admissionReview
Claim.supportingInfo:AdmissionReview.codeexampleExceptionCodes
Claim.supportingInfo:AdmissionReview.reasonexampleMissingToothReasonCodes
Claim.diagnosis.diagnosis[x]exampleICD-10Codes
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConceptrequiredX12278DiagnosisCodes
Claim.diagnosis.typerequiredX12278DiagnosisType
Claim.diagnosis.onAdmissionexampleExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCodeexampleExampleDiagnosisRelatedGroupCodes
Claim.procedure.typeexampleExampleProcedureTypeCodes
Claim.procedure.procedure[x]exampleICD-10ProcedureCodes
Claim.accident.typerequiredhttps://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.revenuerequiredAHANUBCRevenueCodes
Claim.item.categoryrequiredhttps://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrServicerequiredX12278RequestedServiceType
Claim.item.modifierrequiredX12278RequestedServiceType
Claim.item.programCodeexampleExampleProgramReasonCodes
Claim.item.location[x]exampleExampleServicePlaceCodes
Claim.item.location[x]:locationCodeableConceptrequiredX12278LocationType
Claim.item.bodySiteexampleOralSiteCodes
Claim.item.subSiteexampleSurfaceCodes
Claim.item.detail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.categoryexampleBenefitCategoryCodes
Claim.item.detail.productOrServiceexampleUSCLSCodes
Claim.item.detail.modifierexampleModifierTypeCodes
Claim.item.detail.programCodeexampleExampleProgramReasonCodes
Claim.item.detail.subDetail.revenueexampleExampleRevenueCenterCodes
Claim.item.detail.subDetail.categoryexampleBenefitCategoryCodes
Claim.item.detail.subDetail.productOrServiceexampleUSCLSCodes
Claim.item.detail.subDetail.modifierexampleModifierTypeCodes
Claim.item.detail.subDetail.programCodeexampleExampleProgramReasonCodes