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 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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, 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-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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... extension-identifierSubDepartment S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription 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 Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... 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 Σ0..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..*ExtensionExtension
Slice: Unordered, Open by value:url
..... extension-infoChanged 0..1codeOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... modifierExtension ?!Σ0..*(Slice Definition)Extension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagExtension
..... 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.

.... supportingInfo:AdditionalInformation 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: additionalInformation
....... 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.

..... value[x] S1..1Reference(Resource)Data to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:MessageText 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: freeFormMessage
....... 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.

..... value[x] S1..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:InstitutionalEncounter 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: institutionalEncounter
....... 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.

..... value[x] S1..1Reference(PAS Encounter)Data to be provided
..... 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..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-diagnosisRecordedDate S0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... 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-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-productOrServiceCodeEnd S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... extension-epsdtIndicator S0..1booleanOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... extension-nursingHomeResidentialStatus S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..0
..... url 1..1uri"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..1CodeableConceptValue 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 S0..1CodeableConceptOptional 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 S0..1decimalOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... extension-requestedService S0..1Reference(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..1codeOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... modifierExtension ?!Σ0..*(Slice Definition)Extension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagExtension
.... 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 S0..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 S0..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..*PASClaimClaim, Pre-determination or Pre-authorization
... 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
.... extension-identifierSubDepartment 0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
... insurer Σ0..1Reference(PAS Insurer Organization)Target
... 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
.... supportingInfo:AdditionalInformation 0..1BackboneElementSupporting information
..... value[x] 1..1Reference(Resource)Data to be provided
.... supportingInfo:MessageText 0..1BackboneElementSupporting information
..... value[x] 1..1stringData to be provided
.... supportingInfo:InstitutionalEncounter 0..1BackboneElementSupporting information
..... value[x] 1..1Reference(PAS Encounter)Data to be provided
... diagnosis 0..*BackboneElementPertinent diagnosis information
.... extension-diagnosisRecordedDate 0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... 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-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-productOrServiceCodeEnd 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... extension-epsdtIndicator 0..1booleanOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... extension-nursingHomeResidentialStatus 0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
.... extension-nursingHomeLevelOfCare 0..1CodeableConceptOptional 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..1decimalOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... extension-requestedService 0..1Reference(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..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)
.... 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 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
.... unitPrice 0..1MoneyFee, charge or cost per item

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Claim 0..*PASClaimClaim, 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-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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... extension-identifierSubDepartment S0..1stringOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-identifierSubDepartment
.... use ?!Σ0..1codeusual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .

.... type Σ0..1CodeableConceptDescription 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 Σ0..1uriThe namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value Σ0..1stringThe value that is unique
Example General: 123456
.... period Σ0..1PeriodTime period when id is/was valid for use
.... assigner Σ0..1Reference(Organization)Organization that issued id (may be just text)
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... 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 Σ0..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..*ExtensionExtension
Slice: Unordered, Open by value:url
..... extension-infoChanged 0..1codeOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
..... modifierExtension ?!Σ0..*(Slice Definition)Extension
Slice: Unordered, Open by value:url
..... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagExtension
..... 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.

.... supportingInfo:AdditionalInformation 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: additionalInformation
....... 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.

..... value[x] S1..1Reference(Resource)Data to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:MessageText 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: freeFormMessage
....... 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.

..... value[x] S1..1stringData to be provided
..... reason 0..1CodeableConceptExplanation for the information
Binding: MissingToothReasonCodes (example): Reason codes for the missing teeth.

.... supportingInfo:InstitutionalEncounter 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: institutionalEncounter
....... 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.

..... value[x] S1..1Reference(PAS Encounter)Data to be provided
..... 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..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-diagnosisRecordedDate S0..1dateOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate
.... 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-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-productOrServiceCodeEnd S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd
Binding: X12 278 Requested Service Type (required)
.... extension-epsdtIndicator S0..1booleanOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator
.... extension-nursingHomeResidentialStatus S0..1CodeableConceptOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..0
..... url 1..1uri"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..1CodeableConceptValue 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 S0..1CodeableConceptOptional 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 S0..1decimalOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit
.... extension-requestedService S0..1Reference(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..1codeOptional Extensions Element
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-infoChanged
Binding: PAS Information Change Mode Value Set (required)
.... modifierExtension ?!Σ0..*(Slice Definition)Extension
Slice: Unordered, Open by value:url
.... modifierExtension:infoCancelledFlag ?!0..1InfoCancelledFlagExtension
.... 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 S0..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 S0..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.identifier.userequiredIdentifierUse
Claim.identifier.typeextensibleIdentifier Type Codes
Claim.statusrequiredFixed Value: active
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.supportingInfo:AdditionalInformation.categoryexamplePattern: additionalInformation
Claim.supportingInfo:AdditionalInformation.codeexampleExceptionCodes
Claim.supportingInfo:AdditionalInformation.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:MessageText.categoryexamplePattern: freeFormMessage
Claim.supportingInfo:MessageText.codeexampleExceptionCodes
Claim.supportingInfo:MessageText.reasonexampleMissingToothReasonCodes
Claim.supportingInfo:InstitutionalEncounter.categoryexamplePattern: institutionalEncounter
Claim.supportingInfo:InstitutionalEncounter.codeexampleExceptionCodes
Claim.supportingInfo:InstitutionalEncounter.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.extension:nursingHomeResidentialStatus.value[x]:valueCodeableConceptrequiredhttps://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345
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