HL7.FHIR.US.DAVINCI-PAS\PAS Claim Update

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 Update

Defining URL:

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

Version:

1.0.0

Name:

PASClaimUpdate

Title:

PAS Claim Update

Status:

Active as of 2020-12-20T19:17:24+00:00

Definition:

PAS constraints on Claim resource when submitting an update to a previous PAS prior authorization request

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-update

Formal Views of Profile Content

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

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from PASClaim

Summary

Extensions

This structure refers to these extensions:

This structure is derived from PASClaim

Name	Card.	Type	Description & Constraints
Claim	0..*	PASClaim	Claim, Pre-determination or Pre-authorization
supportingInfo	0..*	BackboneElement	Supporting information
extension	0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-infoChanged	0..1	code	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	0..1	InfoCancelledFlag	Extension
item
extension-infoChanged	0..1	code	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	0..1	InfoCancelledFlag	Extension
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaim	Claim, Pre-determination or Pre-authorization
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-levelOfServiceCode	S	0..1	CodeableConcept	Optional 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..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension-identifierSubDepartment	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
use	?!Σ	0..1	code	usual \| official \| temp \| secondary \| old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active \| cancelled \| draft \| entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim \| preauthorization \| predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner \| PractitionerRole)	Author of the claim
insurer	SΣ	0..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest \| MedicationRequest \| VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest \| MedicationRequest \| VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
careTeam	S	0..*	BackboneElement	Members of the care team
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Practitioner \| US Core Organization Profile)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
supportingInfo	S	0..*	(Slice Definition)	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-infoChanged		0..1	code	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	?!Σ	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!	0..1	InfoCancelledFlag	Extension
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]	S	1..1		When it occurred
timingDate			date
timingPeriod			Period
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionReview		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionReview
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]	S	1..1		When it occurred
timingDate			date
timingPeriod			Period
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(Resource)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	string	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:InstitutionalEncounter		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: institutionalEncounter
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(PAS Encounter)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-diagnosisRecordedDate	S	0..1	date	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	(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..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-itemTraceNumber	S	0..1	Identifier	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension-authorizationNumber	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension-administrationReferenceNumber	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension-serviceItemRequestType	S	0..1	CodeableConcept	Optional 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	S	0..1	CodeableConcept	Optional 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-productOrServiceCodeEnd	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension-epsdtIndicator	S	0..1	boolean	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension-nursingHomeResidentialStatus	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]		0..1	(Slice Definition)	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time 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.
extension-nursingHomeLevelOfCare	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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-revenueUnitRateLimit	S	0..1	decimal	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension-requestedService	S	0..1	Reference(PAS Medication Request \| PAS Service Request \| PAS Device Request)	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension-infoChanged		0..1	code	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	?!Σ	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!	0..1	InfoCancelledFlag	Extension
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	(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..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaim	Claim, Pre-determination or Pre-authorization
extension-levelOfServiceCode		0..1	CodeableConcept	Optional 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..1	Identifier	Business Identifier for claim
extension-identifierSubDepartment		0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
insurer	Σ	0..1	Reference(PAS Insurer Organization)	Target
provider	Σ	1..1	Reference(PAS Requestor Organization)	Party responsible for the claim
careTeam		0..*	BackboneElement	Members of the care team
sequence		1..1	positiveInt	Order of care team
provider		1..1	Reference(PAS Practitioner \| US Core Organization Profile)	Practitioner or organization
role		0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification		0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
supportingInfo		0..*	(Slice Definition)	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
supportingInfo:PatientEvent		0..1	BackboneElement	Supporting information
timing[x]		1..1		When it occurred
timingDate			date
timingPeriod			Period
supportingInfo:AdmissionReview		0..1	BackboneElement	Supporting information
timing[x]		1..1		When it occurred
timingDate			date
timingPeriod			Period
supportingInfo:AdditionalInformation		0..1	BackboneElement	Supporting information
value[x]		1..1	Reference(Resource)	Data to be provided
supportingInfo:MessageText		0..1	BackboneElement	Supporting information
value[x]		1..1	string	Data to be provided
supportingInfo:InstitutionalEncounter		0..1	BackboneElement	Supporting information
value[x]		1..1	Reference(PAS Encounter)	Data to be provided
diagnosis		0..*	BackboneElement	Pertinent diagnosis information
extension-diagnosisRecordedDate		0..1	date	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
sequence		1..1	positiveInt	Diagnosis 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..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
insurance	Σ	1..*	BackboneElement	Patient insurance information
sequence	Σ	1..1	positiveInt	Insurance instance identifier
coverage	Σ	1..1	Reference(Coverage)	Insurance information
accident		0..1	BackboneElement	Details of the event
date		1..1	date	When the incident occurred
type		0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
item		1..*	BackboneElement	Product or service provided
extension-itemTraceNumber		0..1	Identifier	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension-authorizationNumber		0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension-administrationReferenceNumber		0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension-serviceItemRequestType		0..1	CodeableConcept	Optional 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..1	CodeableConcept	Optional 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-productOrServiceCodeEnd		0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension-epsdtIndicator		0..1	boolean	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension-nursingHomeResidentialStatus		0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
extension-nursingHomeLevelOfCare		0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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-revenueUnitRateLimit		0..1	decimal	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension-requestedService		0..1	Reference(PAS Medication Request \| PAS Service Request \| PAS Device Request)	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
sequence		1..1	positiveInt	Item instance identifier
careTeamSequence		0..*	positiveInt	Applicable careTeam members
diagnosisSequence		0..*	positiveInt	Applicable diagnoses
informationSequence		0..*	positiveInt	Applicable exception and supporting information
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category		0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier		0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Type (required)
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
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..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
Documentation for this format

This structure is derived from PASClaim

Summary

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from PASClaim

Name	Card.	Type	Description & Constraints
Claim	0..*	PASClaim	Claim, Pre-determination or Pre-authorization
supportingInfo	0..*	BackboneElement	Supporting information
extension	0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-infoChanged	0..1	code	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	0..1	InfoCancelledFlag	Extension
item
extension-infoChanged	0..1	code	Extension URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	0..1	InfoCancelledFlag	Extension
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Claim		0..*	PASClaim	Claim, Pre-determination or Pre-authorization
id	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language.
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-levelOfServiceCode	S	0..1	CodeableConcept	Optional 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..*	Extension	Extensions that cannot be ignored
identifier	S	1..1	Identifier	Business Identifier for claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
extension-identifierSubDepartment	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
use	?!Σ	0..1	code	usual \| official \| temp \| secondary \| old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	Σ	0..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!Σ	1..1	code	active \| cancelled \| draft \| entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	Σ	1..1	CodeableConcept	Category or discipline Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	Σ	1..1	code	claim \| preauthorization \| predetermination Binding: Use (required): The purpose of the Claim: predetermination, preauthorization, claim. Fixed Value: preauthorization
patient	Σ	1..1	Reference(PAS Beneficiary Patient)	The recipient of the products and services
billablePeriod	Σ	0..1	Period	Relevant time frame for the claim
created	Σ	1..1	dateTime	Resource creation date
enterer		0..1	Reference(Practitioner \| PractitionerRole)	Author of the claim
insurer	SΣ	0..1	Reference(PAS Insurer Organization)	Target
provider	SΣ	1..1	Reference(PAS Requestor Organization)	Party responsible for the claim
priority	Σ	1..1	CodeableConcept	Desired processing ugency Binding: ProcessPriorityCodes (example): The timeliness with which processing is required: stat, normal, deferred.
fundsReserve		0..1	CodeableConcept	For whom to reserve funds Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
related		0..*	BackboneElement	Prior or corollary claims
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
claim		0..1	Reference(Claim)	Reference to the related claim
relationship		0..1	CodeableConcept	How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example): Relationship of this claim to a related Claim.
reference		0..1	Identifier	File or case reference
prescription		0..1	Reference(DeviceRequest \| MedicationRequest \| VisionPrescription)	Prescription authorizing services and products
originalPrescription		0..1	Reference(DeviceRequest \| MedicationRequest \| VisionPrescription)	Original prescription if superseded by fulfiller
payee		0..1	BackboneElement	Recipient of benefits payable
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Category of recipient Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
party		0..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson)	Recipient reference
referral		0..1	Reference(ServiceRequest)	Treatment referral
facility		0..1	Reference(Location)	Servicing facility
careTeam	S	0..*	BackboneElement	Members of the care team
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Order of care team
provider	S	1..1	Reference(PAS Practitioner \| US Core Organization Profile)	Practitioner or organization
responsible		0..1	boolean	Indicator of the lead practitioner
role	S	0..1	CodeableConcept	Function within the team Binding: https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98 (required): Codes identifying a provider specialty. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
qualification	S	0..1	CodeableConcept	Practitioner credential or specialization Binding: https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127 (required)
supportingInfo	S	0..*	(Slice Definition)	Supporting information Slice: Unordered, Open by value:category
supportingInfo:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-infoChanged		0..1	code	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	?!Σ	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!	0..1	InfoCancelledFlag	Extension
sequence	S	1..1	positiveInt	Information instance identifier
category	S	1..1	CodeableConcept	Classification of the supplied information Binding: PAS Supporting Info Type Value Set (extensible)
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]		0..1		When it occurred
timingDate			date
timingPeriod			Period
value[x]		0..1		Data to be provided
valueBoolean			boolean
valueString			string
valueQuantity			Quantity
valueAttachment			Attachment
valueReference			Reference(Resource)
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:PatientEvent		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: patientEvent
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]	S	1..1		When it occurred
timingDate			date
timingPeriod			Period
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdmissionReview		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: admissionReview
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
timing[x]	S	1..1		When it occurred
timingDate			date
timingPeriod			Period
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:AdditionalInformation		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: additionalInformation
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(Resource)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:MessageText		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: freeFormMessage
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	string	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
supportingInfo:InstitutionalEncounter		0..1	BackboneElement	Supporting information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Information instance identifier
category		1..1	CodeableConcept	Classification of the supplied information Binding: ClaimInformationCategoryCodes (example): The valuset used for additional information category codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: institutionalEncounter
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
code		0..1	CodeableConcept	Type of information Binding: ExceptionCodes (example): The valuset used for additional information codes.
value[x]	S	1..1	Reference(PAS Encounter)	Data to be provided
reason		0..1	CodeableConcept	Explanation for the information Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.
diagnosis	S	0..*	BackboneElement	Pertinent diagnosis information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-diagnosisRecordedDate	S	0..1	date	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	S	1..1	positiveInt	Diagnosis instance identifier
diagnosis[x]	S	1..1	(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..1	CodeableConcept	Nature of illness or problem Binding: X12 278 Diagnosis Code Value Set (required)
type	S	0..1	CodeableConcept	Timing or nature of the diagnosis Binding: X12 278 Diagnosis Type Value Set (required)
onAdmission		0..1	CodeableConcept	Present on admission Binding: ExampleDiagnosisOnAdmissionCodes (example): Present on admission.
packageCode		0..1	CodeableConcept	Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example): The DRG codes associated with the diagnosis.
procedure		0..*	BackboneElement	Clinical procedures performed
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Procedure instance identifier
type		0..*	CodeableConcept	Category of Procedure Binding: ExampleProcedureTypeCodes (example): Example procedure type codes.
date		0..1	dateTime	When the procedure was performed
procedure[x]		1..1		Specific clinical procedure Binding: ICD-10ProcedureCodes (example): Example ICD10 Procedure codes.
procedureCodeableConcept			CodeableConcept
procedureReference			Reference(Procedure)
udi		0..*	Reference(Device)	Unique device identifier
insurance	SΣ	1..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	SΣ	1..1	positiveInt	Insurance instance identifier
focal	Σ	1..1	boolean	Coverage to be used for adjudication Fixed Value: true
identifier		0..1	Identifier	Pre-assigned Claim number
coverage	SΣ	1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
preAuthRef		0..*	string	Prior authorization reference number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
accident	S	0..1	BackboneElement	Details of the event
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
date	S	1..1	date	When the incident occurred
type	S	0..1	CodeableConcept	The nature of the accident Binding: https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362 (required): Codes identifying an accompanying cause of an illness, injury or an accident. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
location[x]		0..1	Address	Where the event occurred
item	S	1..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension-itemTraceNumber	S	0..1	Identifier	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
extension-authorizationNumber	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber
extension-administrationReferenceNumber	S	0..1	string	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber
extension-serviceItemRequestType	S	0..1	CodeableConcept	Optional 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	S	0..1	CodeableConcept	Optional 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-productOrServiceCodeEnd	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd Binding: X12 278 Requested Service Type (required)
extension-epsdtIndicator	S	0..1	boolean	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
extension-nursingHomeResidentialStatus	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus"
value[x]		0..1	(Slice Definition)	Value of extension Slice: Unordered, Closed by type:$this
value[x]:valueCodeableConcept		0..1	CodeableConcept	Value of extension Binding: https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345 (required): Codes specifying the status of a nursing home resident at the time 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.
extension-nursingHomeLevelOfCare	S	0..1	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare Binding: https://valueset.x12.org/x217/005010/request/2000F/SV1/1/20/00/1337 (required): Codes specifying the level of care provided by a nursing home facility. 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-revenueUnitRateLimit	S	0..1	decimal	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
extension-requestedService	S	0..1	Reference(PAS Medication Request \| PAS Service Request \| PAS Device Request)	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService
extension-infoChanged		0..1	code	Optional Extensions Element URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged Binding: PAS Information Change Mode Value Set (required)
modifierExtension	?!Σ	0..*	(Slice Definition)	Extension Slice: Unordered, Open by value:url
modifierExtension:infoCancelledFlag	?!	0..1	InfoCancelledFlag	Extension
sequence	S	1..1	positiveInt	Item instance identifier
careTeamSequence	S	0..*	positiveInt	Applicable careTeam members
diagnosisSequence	S	0..*	positiveInt	Applicable diagnoses
procedureSequence		0..*	positiveInt	Applicable procedures
informationSequence	S	0..*	positiveInt	Applicable exception and supporting information
revenue	S	0..1	CodeableConcept	Revenue or cost center code Binding: AHA NUBC Revenue Value Set (required)
category	S	0..1	CodeableConcept	Benefit classification Binding: https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365 (required): Codes identifying the classification of service. These codes are listed within an X12 implementation guide (TR3) and maintained by X12. All X12 work products are copyrighted. See their website for licensing terms and conditions.
productOrService	S	1..1	CodeableConcept	Billing, service, product, or drug code Binding: X12 278 Requested Service Type (required)
modifier	S	0..*	CodeableConcept	Product or service billing modifiers Binding: X12 278 Requested Service Type (required)
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]	S	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	S	0..1	(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..1	CodeableConcept	Place of service or where product was supplied Binding: X12 278 Health Care Service Location Type Value Set (required)
quantity	S	0..1	SimpleQuantity	Count of products or services
unitPrice	S	0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
encounter		0..*	Reference(Encounter)	Encounters related to this billed item
detail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
subDetail		0..*	BackboneElement	Product or service provided
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Item instance identifier
revenue		0..1	CodeableConcept	Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
category		0..1	CodeableConcept	Benefit classification Binding: BenefitCategoryCodes (example): Benefit categories such as: oral-basic, major, glasses.
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
udi		0..*	Reference(Device)	Unique device identifier
total		0..1	Money	Total claim cost
Documentation for this format

Other representations of profile: Schematron

Terminology Bindings

Path	Conformance	ValueSet / Code
Claim.language	preferred	CommonLanguages Max Binding: AllLanguages
Claim.identifier.use	required	IdentifierUse
Claim.identifier.type	extensible	Identifier Type Codes
Claim.status	required	Fixed Value: active
Claim.type	extensible	ClaimTypeCodes
Claim.subType	example	ExampleClaimSubTypeCodes
Claim.use	required	Fixed Value: preauthorization
Claim.priority	example	ProcessPriorityCodes
Claim.fundsReserve	example	Funds Reservation Codes
Claim.related.relationship	example	ExampleRelatedClaimRelationshipCodes
Claim.payee.type	example	Claim Payee Type Codes
Claim.careTeam.role	required	https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98
Claim.careTeam.qualification	required	https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127
Claim.supportingInfo.category	extensible	PASSupportingInfoType
Claim.supportingInfo.code	example	ExceptionCodes
Claim.supportingInfo.reason	example	MissingToothReasonCodes
Claim.supportingInfo:PatientEvent.category	example	Pattern: patientEvent
Claim.supportingInfo:PatientEvent.code	example	ExceptionCodes
Claim.supportingInfo:PatientEvent.reason	example	MissingToothReasonCodes
Claim.supportingInfo:AdmissionReview.category	example	Pattern: admissionReview
Claim.supportingInfo:AdmissionReview.code	example	ExceptionCodes
Claim.supportingInfo:AdmissionReview.reason	example	MissingToothReasonCodes
Claim.supportingInfo:AdditionalInformation.category	example	Pattern: additionalInformation
Claim.supportingInfo:AdditionalInformation.code	example	ExceptionCodes
Claim.supportingInfo:AdditionalInformation.reason	example	MissingToothReasonCodes
Claim.supportingInfo:MessageText.category	example	Pattern: freeFormMessage
Claim.supportingInfo:MessageText.code	example	ExceptionCodes
Claim.supportingInfo:MessageText.reason	example	MissingToothReasonCodes
Claim.supportingInfo:InstitutionalEncounter.category	example	Pattern: institutionalEncounter
Claim.supportingInfo:InstitutionalEncounter.code	example	ExceptionCodes
Claim.supportingInfo:InstitutionalEncounter.reason	example	MissingToothReasonCodes
Claim.diagnosis.diagnosis[x]	example	ICD-10Codes
Claim.diagnosis.diagnosis[x]:diagnosisCodeableConcept	required	X12278DiagnosisCodes
Claim.diagnosis.type	required	X12278DiagnosisType
Claim.diagnosis.onAdmission	example	ExampleDiagnosisOnAdmissionCodes
Claim.diagnosis.packageCode	example	ExampleDiagnosisRelatedGroupCodes
Claim.procedure.type	example	ExampleProcedureTypeCodes
Claim.procedure.procedure[x]	example	ICD-10ProcedureCodes
Claim.accident.type	required	https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362
Claim.item.extension:nursingHomeResidentialStatus.value[x]:valueCodeableConcept	required	https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345
Claim.item.revenue	required	AHANUBCRevenueCodes
Claim.item.category	required	https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365
Claim.item.productOrService	required	X12278RequestedServiceType
Claim.item.modifier	required	X12278RequestedServiceType
Claim.item.programCode	example	ExampleProgramReasonCodes
Claim.item.location[x]	example	ExampleServicePlaceCodes
Claim.item.location[x]:locationCodeableConcept	required	X12278LocationType
Claim.item.bodySite	example	OralSiteCodes
Claim.item.subSite	example	SurfaceCodes
Claim.item.detail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.category	example	BenefitCategoryCodes
Claim.item.detail.productOrService	example	USCLSCodes
Claim.item.detail.modifier	example	ModifierTypeCodes
Claim.item.detail.programCode	example	ExampleProgramReasonCodes
Claim.item.detail.subDetail.revenue	example	ExampleRevenueCenterCodes
Claim.item.detail.subDetail.category	example	BenefitCategoryCodes
Claim.item.detail.subDetail.productOrService	example	USCLSCodes
Claim.item.detail.subDetail.modifier	example	ModifierTypeCodes
Claim.item.detail.subDetail.programCode	example	ExampleProgramReasonCodes