description: PAS constraints on Claim resource mandating support for elements relevant to the prior authorization request
package_name: hl7.fhir.us.davinci
derivation: constraint
name: PASClaim
type: Claim
elements:
  patient:
    type: Reference
    refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-beneficiary']
    index: 5
  insurance:
    mustSupport: true
    index: 88
    elements:
      sequence: {mustSupport: true, index: 89}
      focal:
        pattern: {type: Boolean, value: true}
        index: 90
      coverage:
        type: Reference
        mustSupport: true
        refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-coverage']
        index: 91
  diagnosis:
    mustSupport: true
    index: 79
    extensions:
      recordedDate: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate', min: 0, max: 1, type: Extension, short: The date that a diagnosis was recorded. (HIxx-4), mustSupport: true, index: 81}
    elements:
      extension:
        index: 80
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            recordedDate:
              match: {url: null}
              schema: {type: Extension, short: The date that a diagnosis was recorded. (HIxx-4), mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-diagnosisRecordedDate', index: 81}
              min: 0
              max: 1
      sequence: {mustSupport: true, index: 82}
      diagnosis:
        mustSupport: true
        choices: [diagnosisCodeableConcept]
        index: 84
      diagnosisCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: diagnosis, index: 85}
      type:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278DiagnosisType'}
        mustSupport: true
        index: 87
  supportingInfo:
    mustSupport: true
    index: 27
    elements:
      sequence: {mustSupport: true, index: 28}
      category:
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/us/davinci-pas/ValueSet/PASSupportingInfoType'}
        mustSupport: true
        index: 29
    slicing:
      rules: open
      description: Slice based on the different types of supporting information that can be included in a authorization request.
      discriminator:
      - {path: category, type: value}
      min: null
      slices:
        PatientEvent:
          match:
            category:
              coding:
              - {code: patientEvent, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Information about the dates of the event that are being requested.
            index: 30
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: patientEvent, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 31
              timing:
                mustSupport: true
                choices: []
                index: 33
              timingDate:
                type: date
                constraint:
                  FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                index: 34
              timingPeriod:
                type: Period
                index: 35
                elements:
                  start:
                    constraint:
                      FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                    index: 36
                  end:
                    constraint:
                      FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                    index: 37
              value:
                choices: []
                index: 39
            required: [timing]
        AdmissionDates:
          match:
            category:
              coding:
              - {code: admissionDates, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Information about the admission dates of a hospital admission being requested.
            index: 40
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: admissionDates, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 41
              timing:
                mustSupport: true
                choices: []
                index: 43
              timingDate:
                type: date
                constraint:
                  FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                index: 44
              timingPeriod:
                type: Period
                index: 45
                elements:
                  start:
                    constraint:
                      FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                    index: 46
                  end:
                    constraint:
                      FullDateRule: {human: Dates need to be a full date - YYYY-MM-DD, source: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim', severity: error, expression: this.empty() or this.length() = 10}
                    index: 47
              value:
                choices: []
                index: 49
            required: [timing]
        DischargeDates:
          match:
            category:
              coding:
              - {code: dischargeDates, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Information about the discharge dates of a hospital admission being requested.
            index: 50
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: dischargeDates, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 51
              timing:
                mustSupport: true
                choices: [timingDate]
                index: 53
              timingDate: {type: date, mustSupport: true, choiceOf: timing, index: 54}
              value:
                choices: []
                index: 57
            required: [timingDate, timing]
        AdditionalInformation:
          match:
            category:
              coding:
              - {code: additionalInformation, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Send additional paperwork or supporting information for the request.  This can be most commonly a PASDocumentReference profile although any type of information is allowed.
            index: 58
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: additionalInformation, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 59
              timing:
                choices: []
                index: 61
              value:
                mustSupport: true
                choices: [valueReference]
                index: 63
              valueReference:
                type: Reference
                mustSupport: true
                choiceOf: value
                refers: ['http://hl7.org/fhir/StructureDefinition/Resource']
                index: 64
            required: [valueReference, value]
        MessageText:
          match:
            category:
              coding:
              - {code: freeFormMessage, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Send text messages to the UMO.
            index: 65
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: freeFormMessage, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 66
              timing:
                choices: []
                index: 68
              value:
                mustSupport: true
                choices: [valueString]
                index: 70
              valueString: {type: string, mustSupport: true, choiceOf: value, index: 71}
            required: [valueString, value]
        InstitutionalEncounter:
          match:
            category:
              coding:
              - {code: institutionalEncounter, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
          schema:
            short: Information about a hospital claim being requested.
            index: 72
            elements:
              category:
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: institutionalEncounter, system: 'http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType'}
                index: 73
              timing:
                choices: []
                index: 75
              value:
                mustSupport: true
                choices: [valueReference]
                index: 77
              valueReference:
                type: Reference
                mustSupport: true
                choiceOf: value
                refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-encounter']
                index: 78
            required: [valueReference, value]
  use:
    pattern: {type: Code, value: preauthorization}
    index: 4
  item:
    mustSupport: true
    index: 98
    extensions:
      certificationType: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType', min: 0, max: 1, type: Extension, short: A code representing the type of certification being requested (UM02), mustSupport: true, index: 104}
      nursingHomeLevelOfCare: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare', min: 0, max: 1, type: Extension, short: 'A code specifying the level of care provided by a nursing home facility. (SV120, SV210)', mustSupport: true, index: 109}
      productOrServiceCodeEnd: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd', min: 0, max: 1, type: Extension, short: Used to provide the last code in a series of codes for the service being requested., mustSupport: true, index: 105}
      epsdtIndicator: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator', min: 0, max: 1, type: Extension, short: An indicator of whether early and periodic screen for diagnosis and treatment of children is involved., mustSupport: true, index: 106}
      requestedService: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService', min: 0, max: 1, type: Extension, short: The details of the service being requested., mustSupport: true, index: 111}
      authorizationNumber: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber', min: 0, max: 1, type: Extension, short: A string assigned by the UMO to an authorized review outcome associated with this service item., mustSupport: true, index: 101}
      revenueUnitRateLimit: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit', min: 0, max: 1, type: Extension, short: The limit on the rate per unit of revenue for hospital accomodation. (SV206), mustSupport: true, index: 110}
      itemTraceNumber: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber', min: 0, type: Extension, short: Uniquely identifies this claim item. (2000F-TRN), mustSupport: true, index: 100}
      administrationReferenceNumber: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber', min: 0, max: 1, type: Extension, short: A string assigned by the UMO to the original disallowed review outcome associated with this service item., mustSupport: true, index: 102}
      requestType: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType', min: 0, max: 1, type: Extension, short: A string assigned by the UMO to the original disallowed review outcome associated with this service item., mustSupport: true, index: 103}
      nursingHomeResidentialStatus:
        url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
        type: Extension
        short: A code specifying the status of a nursing home resident at the time of service. (SV209)
        mustSupport: true
        index: 107
        elements:
          valueCodeableConcept:
            binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345'}
            index: 108
    elements:
      category:
        binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2000F/UM/1/03/00/1365'}
        mustSupport: true
        index: 117
      diagnosisSequence: {mustSupport: true, index: 114}
      modifier:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType'}
        mustSupport: true
        index: 119
      revenue:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pas/ValueSet/AHANUBCRevenueCodes'}
        mustSupport: true
        index: 116
      locationCodeableConcept: {type: CodeableConcept, mustSupport: true, choiceOf: location, index: 124}
      serviced:
        mustSupport: true
        choices: []
        index: 121
      careTeamSequence: {mustSupport: true, index: 113}
      productOrService:
        binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType'}
        mustSupport: true
        index: 118
      extension:
        index: 99
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: null
          slices:
            certificationType:
              match: {url: null}
              schema: {type: Extension, short: A code representing the type of certification being requested (UM02), mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-certificationType', index: 104}
              min: 0
              max: 1
            nursingHomeLevelOfCare:
              match: {url: null}
              schema: {type: Extension, short: 'A code specifying the level of care provided by a nursing home facility. (SV120, SV210)', mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeLevelOfCare', index: 109}
              min: 0
              max: 1
            productOrServiceCodeEnd:
              match: {url: null}
              schema: {type: Extension, short: Used to provide the last code in a series of codes for the service being requested., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-productOrServiceCodeEnd', index: 105}
              min: 0
              max: 1
            epsdtIndicator:
              match: {url: null}
              schema: {type: Extension, short: An indicator of whether early and periodic screen for diagnosis and treatment of children is involved., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-epsdtIndicator', index: 106}
              min: 0
              max: 1
            requestedService:
              match: {url: null}
              schema: {type: Extension, short: The details of the service being requested., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService', index: 111}
              min: 0
              max: 1
            authorizationNumber:
              match: {url: null}
              schema: {type: Extension, short: A string assigned by the UMO to an authorized review outcome associated with this service item., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizationNumber', index: 101}
              min: 0
              max: 1
            revenueUnitRateLimit:
              match: {url: null}
              schema: {type: Extension, short: The limit on the rate per unit of revenue for hospital accomodation. (SV206), mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-revenueUnitRateLimit', index: 110}
              min: 0
              max: 1
            itemTraceNumber:
              match: {url: null}
              schema: {type: Extension, short: Uniquely identifies this claim item. (2000F-TRN), mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber', index: 100}
              min: 0
            administrationReferenceNumber:
              match: {url: null}
              schema: {type: Extension, short: A string assigned by the UMO to the original disallowed review outcome associated with this service item., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-administrationReferenceNumber', index: 102}
              min: 0
              max: 1
            requestType:
              match: {url: null}
              schema: {type: Extension, short: A string assigned by the UMO to the original disallowed review outcome associated with this service item., mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-serviceItemRequestType', index: 103}
              min: 0
              max: 1
            nursingHomeResidentialStatus:
              match: {url: null}
              schema:
                type: Extension
                short: A code specifying the status of a nursing home resident at the time of service. (SV209)
                mustSupport: true
                url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-nursingHomeResidentialStatus
                index: 107
                elements:
                  valueCodeableConcept:
                    binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2000F/SV2/1/09/00/1345'}
                    index: 108
      informationSequence: {mustSupport: true, index: 115}
      sequence: {mustSupport: true, index: 112}
      quantity: {mustSupport: true, index: 126}
      location:
        mustSupport: true
        choices: [locationCodeableConcept]
        index: 123
      unitPrice: {mustSupport: true, index: 127}
  extension:
    index: 0
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: null
      slices:
        levelOfServiceType:
          match: {url: null}
          schema: {type: Extension, short: A code specifying the level of service being requested (UM06), mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode', index: 1}
          min: 0
          max: 1
  insurer:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-insurer']
    index: 6
  accident:
    mustSupport: true
    index: 92
    elements:
      date: {mustSupport: true, index: 93}
      type:
        binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2000E/UM/1/05/01/1362'}
        mustSupport: true
        index: 94
      location:
        choices: [locationAddress]
        index: 96
      locationAddress: {type: Address, choiceOf: location, index: 97}
  status:
    pattern: {type: Code, value: active}
    index: 3
  identifier: {type: Identifier, mustSupport: true, index: 2}
  provider:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-requestor']
    index: 7
  careTeam:
    mustSupport: true
    index: 8
    extensions:
      careTeamClaimScope: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope', min: 1, max: 1, type: Extension, mustSupport: true, index: 10}
    elements:
      extension:
        index: 9
        slicing:
          rules: open
          ordered: false
          discriminator:
          - {path: url, type: value}
          min: 1
          slices:
            careTeamClaimScope:
              match: {url: null}
              schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope', index: 10}
              min: 1
              max: 1
      sequence: {mustSupport: true, index: 11}
      provider:
        type: Reference
        mustSupport: true
        refers: ['http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-organization', 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-practitioner']
        index: 12
      role: {mustSupport: true, index: 13}
      qualification: {mustSupport: true, index: 14}
    required: [extension]
    slicing:
      rules: open
      description: Slice based on whether the care team member belongs to the overall claim or to an individual claim item.
      discriminator:
      - {path: 'extension(''http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope'').value as boolean', type: value}
      min: null
      slices:
        OverallClaimMember:
          match:
            extension('http://hl7:
              org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope'): {value as boolean: null}
          schema:
            array: true
            max: 14
            index: 15
            extensions:
              careTeamClaimScope:
                url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
                type: Extension
                mustSupport: true
                index: 17
                elements:
                  valueBoolean:
                    pattern: {type: Boolean, value: true}
                    index: 18
            elements:
              extension:
                mustSupport: true
                index: 16
                slicing:
                  rules: open
                  ordered: false
                  discriminator:
                  - {path: url, type: value}
                  min: 1
                  slices:
                    careTeamClaimScope:
                      match: {url: null}
                      schema:
                        type: Extension
                        mustSupport: true
                        url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
                        index: 17
                        elements:
                          valueBoolean:
                            pattern: {type: Boolean, value: true}
                            index: 18
              role:
                binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2010EA/NM1/1/01/00/98'}
                index: 19
              qualification:
                binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2010EA/PRV/1/03/00/127'}
                index: 20
            required: [extension]
        ItemClaimMember:
          match:
            extension('http://hl7:
              org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope'): {value as boolean: null}
          schema:
            array: true
            max: 10
            index: 21
            extensions:
              careTeamClaimScope:
                url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
                type: Extension
                mustSupport: true
                index: 23
                elements:
                  valueBoolean:
                    pattern: {type: Boolean, value: false}
                    index: 24
            elements:
              extension:
                mustSupport: true
                index: 22
                slicing:
                  rules: open
                  ordered: false
                  discriminator:
                  - {path: url, type: value}
                  min: 1
                  slices:
                    careTeamClaimScope:
                      match: {url: null}
                      schema:
                        type: Extension
                        mustSupport: true
                        url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope
                        index: 23
                        elements:
                          valueBoolean:
                            pattern: {type: Boolean, value: false}
                            index: 24
              role:
                binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2010F/NM1/1/01/00/98'}
                index: 25
              qualification:
                binding: {strength: required, valueSet: 'https://valueset.x12.org/x217/005010/request/2010F/PRV/1/03/00/127'}
                index: 26
            required: [extension]
package_version: pas-1.1.0
extensions:
  levelOfServiceType: {url: 'http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-levelOfServiceCode', min: 0, max: 1, type: Extension, short: A code specifying the level of service being requested (UM06), mustSupport: true, index: 1}
class: profile
kind: resource
url: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claim
base: http://hl7.org/fhir/StructureDefinition/Claim
version: 1.1.0
required: [identifier, item]