Claim $submit-preauthorization

post/Claim/$submit-preauthorization
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This resource contains the financial details for provider services for a patient visit or treatment. Healthcare organizations can use this resource to request reimbursement while payers can review this resource to process claims and respond with the ClaimResponse resource. 

You can submit, check, or add to claim information using one of the supported operations.

$submit-preauthorization

This operation allows you to submit a preauthorization request. You must complete the preauthorization (AKA preapproval or precertification) process to confirm that a payer intends to cover a high cost service or prescription before providing it to a patient. 

Request parameters and payload

cURL request example

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curl 'https://api.redoxengine.com/fhir/R4/{destinationSlug}/{environmentFlag}/Claim/$submit-preauthorization' \
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--request POST \
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--header 'Authorization: Bearer $API_TOKEN' \
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--header 'Content-Type: application/fhir+json' \
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--data '{
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"resourceType": "Bundle",
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"id": "RedoxMedicationClaimRequestBundleExample",
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"type": "collection",
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"identifier": {
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"system": "urn:ietf:rfc:3986",
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"value": "urn:uuid:ef62bfe0-03fc-4509-9f9a-8fea04c1d025"
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},
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"timestamp": "2021-08-18T16:18:43.649Z",
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"entry": [
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{
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"resource": {
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"resourceType": "Claim",
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"id": "RedoxPAMedicationClaimExample",
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"status": "active",
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"use": "preauthorization",
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"insurance": [
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{
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"focal": true,
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"sequence": 1,
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"coverage": {
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"reference": "Coverage/RedoxPACoverageExample"
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}
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}
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],
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"item": [
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{
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"extension": [
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{
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"url": "http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-requestedService",
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"valueReference": {
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"reference": "MedicationRequest/RedoxPAMedicationRequestExample"
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}
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}
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],
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"sequence": 1,
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"productOrService": {
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"coding": [
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{
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"code": "372754009",
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"system": "http://snomed.info/sct"
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}
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],
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"text": "Calan SR 240MG"
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}
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}
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],
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"identifier": [
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{
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"type": {
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"coding": [
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{
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"code": "ClaimID"
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}
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]
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},
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"value": "urn:uuid:97b8d6d0-ac3d-411a-b32a-e1d237aceb6a"
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}
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],
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"type": {
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"coding": [
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{
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"code": "pharmacy",
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"system": "http://terminology.hl7.org/CodeSystem/claim-type"
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}
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]
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},
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"patient": {
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"reference": "Patient/RedoxPABeneficiaryExample"
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},
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"created": "2021-08-18T16:27:49.101Z",
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"enterer": {
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"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
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},
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"insurer": {
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"reference": "Organization/RedoxPAInsurerOrganizationExample"
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},
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"provider": {
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"reference": "Organization/RedoxPARequestorOrganizationExample"
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},
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"priority": {
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"coding": [
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{
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"code": "normal",
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"system": "http://terminology.hl7.org/CodeSystem/processpriority"
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}
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]
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},
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"diagnosis": [
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{
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"sequence": 1,
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"diagnosisCodeableConcept": {
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"coding": [
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{
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"code": "I10",
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"system": "http://hl7.org/fhir/sid/icd-10-cm",
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"display": "Essential (Primary) Hypertension"
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}
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]
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}
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "MedicationRequest",
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"id": "RedoxPAMedicationRequestExample",
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"intent": "order",
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"dispenseRequest": {
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"expectedSupplyDuration": {
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"system": "http://unitsofmeasure.org",
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"code": "d",
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"value": 30
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},
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"quantity": {
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"value": 60
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},
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"performer": {
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"reference": "Organization/RedoxPAPharmacyOrganizationExample"
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}
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},
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"status": "active",
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"subject": {
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"reference": "Patient/RedoxPABeneficiaryExample"
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},
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"requester": {
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"reference": "PractitionerRole/RedoxPAPractitionerRoleExamplePat"
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},
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"authoredOn": "2021-08-18T17:44:25.704Z",
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"medicationCodeableConcept": {
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"coding": [
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{
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"code": "372754009",
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"system": "http://snomed.info/sct"
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}
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],
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"text": "Calan SR 240MG"
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},
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"dosageInstruction": [
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{
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"doseAndRate": [
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{
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"doseQuantity": {
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"value": 240,
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"code": "mg",
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"system": "http://unitsofmeasure.org"
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}
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}
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],
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"text": "Take 1 tablet two times a day until gone"
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "Patient",
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"id": "RedoxPABeneficiaryExample",
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"identifier": [
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{
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"system": "urn:redox:MRN",
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"value": "M23462346"
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}
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],
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"name": [
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{
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"given": [
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"Timothy",
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"Paul"
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],
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"family": "Bixby"
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}
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],
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"gender": "male",
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"birthDate": "2008-01-06"
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}
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},
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{
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"resource": {
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"resourceType": "Coverage",
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"id": "RedoxPACoverageExample",
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"class": [
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{
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"type": {
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"coding": [
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{
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"code": "group",
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"system": "http://terminology.hl7.org/CodeSystem/coverage-class"
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}
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]
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},
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"value": "GRP2245"
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}
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],
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"status": "active",
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"beneficiary": {
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"reference": "Patient/RedoxPABeneficiaryExample"
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},
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"payor": [
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{
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"reference": "Organization/RedoxPAInsurerOrganizationExample"
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}
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],
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"subscriber": {
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"reference": "Patient/RedoxPABeneficiaryExample"
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},
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"subscriberId": "T75644"
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}
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},
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{
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"resource": {
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"resourceType": "Organization",
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"id": "RedoxPARequestorOrganizationExample",
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"active": true,
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"name": "Good Health Clinics",
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"address": [
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{
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"line": [
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"123 Main St."
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],
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"city": "Madison",
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"district": "Dane",
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"state": "WI",
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"postalCode": "53703",
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"country": "USA"
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "Organization",
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"id": "RedoxPAInsurerOrganizationExample",
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"active": true,
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"name": "Aetna",
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"address": [
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{
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"line": [
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"PO Box 14080"
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],
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"city": "Lexington",
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"district": "Fayette",
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"state": "KY",
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"postalCode": "40512-4079",
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"country": "USA"
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "Organization",
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"id": "RedoxPAPharmacyOrganizationExample",
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"active": true,
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"name": "Rehome Pharmacy",
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"address": [
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{
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"line": [
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"123 Fake St."
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],
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"city": "Madison",
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"district": "Dane",
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"state": "WI",
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"postalCode": "53703",
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"country": "USA"
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "PractitionerRole",
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"id": "RedoxPAPractitionerRoleExamplePat",
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"practitioner": {
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"reference": "Practitioner/RedoxPAPractitionerExamplePat"
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},
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"organization": {
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"reference": "Organization/RedoxPARequestorOrganizationExample"
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},
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"location": [
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{
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"display": "1st Street Family Clinic"
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}
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],
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"specialty": [
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{
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"coding": [
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{
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"code": "394579002",
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"system": "http://snomed.info/sct",
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"display": "Cardiology"
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}
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]
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}
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]
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}
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},
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{
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"resource": {
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"resourceType": "Practitioner",
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"id": "RedoxPAPractitionerExamplePat",
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"identifier": [
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{
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"system": "http://hl7.org/fhir/sid/us-npi",
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"value": "4356789876"
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}
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],
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"name": [
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{
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"given": [
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"Pat"
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],
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"family": "Granite"
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}
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],
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"address": [
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{
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"line": [
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"123 Main St."
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],
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"city": "Madison",
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"district": "Dane",
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"state": "WI",
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"postalCode": "53703",
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"country": "USA"
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}
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],
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"telecom": [
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{
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"value": "+16085551234"
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}
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]
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}
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}
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]
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}'

Request Body Schema

  • resourceType
    required, string

    Identifies the type of the resource

    Value: Bundle
  • identifier
    required, object

    A persistent identifier for the bundle that won't change as a bundle is copied from server to server.

    • system
      string

      Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

    • value
      string

      The portion of the identifier typically relevant to the user and which is unique within the context of the system.

  • type
    required, string

    Indicates the purpose of this bundle - how it is intended to be used.

    Value: collection
  • timestamp
    required, string

    The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

  • entry
    required, Array of Claim, Patient, MedicationRequest, ServiceRequest, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, DocumentReference or Other

    An array of FHIR resources. At a minimum, a Claim Request should include the following entries:

    • Claim - the main prior auth request resource
    • Patient - the patient the claim is about
    • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
    • Coverage - the patient's insurance

    Additional resources such as MedicationRequest or ServiceRequest may also be included to communicate additional information about the claim.

      An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

    • resource
      required, object

      A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

      • resourceType
        required, string

        Identifies the type of the resource

        Value: Claim
      • identifier
        required, Array of object

        An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

        • value
          string

          The portion of the identifier typically relevant to the user and which is unique within the context of the system.

      • status
        required, string

        The status of the resource instance.

        Value: active
      • type
        required, object

        Type of claim. Example Codes

        The recommended system is http://terminology.hl7.org/CodeSystem/claim-type. Typical values include

        • pharmacy - Pharmacy claims for goods and services
        • professional - Typically outpatient claims such as Psychological, Chiropractor, rehabilitative, consulting
        • institutional - Hospital, clinic and other inpatient claims
        • coding
          Array of object

          A reference to a code defined by a terminology system.

          • system
            string

            The identification of the code system that defines the meaning of the symbol in the code.

          • code
            string

            A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

        • text
          string

          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      • use
        required, string

        A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

        Value: preauthorization
      • patient
        required, object

        The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

        Must be a resource of type Patient.

        • reference
          string

          A reference to a Patient resource

      • created
        required, string

        The date this resource was created.

      • provider
        required, object

        The provider which is responsible for the claim, predetermination or preauthorization.

        Must be a resource of type Organization.

        • reference
          string

          A reference to an Organization resource

      • priority
        required, object

        The provider-required urgency of processing the request. Typical values include: stat, routine, and deferred. If sending one of these statuses, use the system http://terminology.hl7.org/CodeSystem/processpriority

        • coding
          Array of object

          A reference to a code defined by a terminology system.

          • system
            string

            The identification of the code system that defines the meaning of the symbol in the code.

          • code
            string

            A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

        • text
          string

          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      • insurance
        required, Array of object

        Financial instruments for reimbursement for the health care products and services specified on the claim.

        • sequence
          required, number

          A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

        • focal
          required, boolean

          A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

          Value: true
        • coverage
          required, object

          Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

          Must be a resource of type Coverage.

          • reference
            string

            A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

      • item
        required, Array of object

        A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

        • sequence
          required, number

          A number to uniquely identify item entries.

        • productOrService
          required, object

          For prior auth, the requestedService extension carries more information than this field, and this field should just duplicate the product or service code found in that resource.

          • coding
            Array of object

            A reference to a code defined by a terminology system.

            • system
              string

              The identification of the code system that defines the meaning of the symbol in the code.

            • code
              string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

        • extension
          Array of itemTraceNumber, administrationReferenceNumber, requestedService or Other

          A set of additional fields about the item. For medication prior auth, the requestedService extension must be present with a reference to a MedicationRequest resource. For procedures, a ServiceRequest resource is used.

            Uniquely identifies this claim item. (2000F-TRN)

            See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

          • url
            required, string

            Source of the definition for the extension code - a logical name or a URL.

            Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
          • valueIdentifier
            object

            Uniquely identifies this claim item

            • value
              string

              The portion of the identifier typically relevant to the user and which is unique within the context of the system.

        • informationSequence
          Array of number

          Exceptions, special conditions and supporting information applicable for this service or product.

        • modifier
          Array of object

          Item typification or modifiers codes to convey additional context for the product or service.

          • coding
            Array of object

            A reference to a code defined by a terminology system.

            • system
              string

              The identification of the code system that defines the meaning of the symbol in the code.

            • code
              string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

        • quantity
          object

          The number of repetitions of a service or product.

          • value
            number

            The value of the measured amount. The value includes an implicit precision in the presentation of the value.

          • _value
            object

            This element contains extensions for value. Depending on the extensions present it could be used in place of value or contain additional information about value. See the extension element for more details on the possible extensions being sent.

            • extension
              Array of Precision or Other

              A Precision extension allows the communication of values more precise than a JSON number, for example, 3.10 as opposed to just 3.1.

                Explicit precision of the number. If the actual value is 3.10, the value field will contain the number 3.1 while the precision extension will contain 2.

                See http://hl7.org/fhir/StructureDefinition/quantity-precision for more information

              • url
                required, string

                Source of the definition for the extension code - a logical name or a URL.

                Value: http://hl7.org/fhir/StructureDefinition/quantity-precision
              • valueInteger
                required, number

                Number of significant decimal places after the decimal.

          • unit
            string

            A human-readable form of the unit.

      • enterer
        object

        Individual who created the claim, predetermination or preauthorization.

        Must be a resource of type PractitionerRole.

        • reference
          string

          A reference to PractitionerRole resource, which should point to both Practitioner and Organization.

      • insurer
        object

        The Insurer who is target of the request.

        Must be a resource of type Organization.

        • reference
          string

          A reference to an Organization resource

      • related
        Array of object

        Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

        • claim
          object

          Reference to a related claim.

          Must be a resource of type Claim.

          • reference
            string

            Contains the resource ID of the original claim that this resource is updating

        • relationship
          object

          When modifying a prior claim, set this to code='prior' and system='http://terminology.hl7.org/CodeSystem/ex-relatedclaimrelationship'

          • coding
            Array of object

            A reference to a code defined by a terminology system.

            • system
              string

              The identification of the code system that defines the meaning of the symbol in the code.

            • code
              string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      • careTeam
        Array of OverallClaimMember, ItemClaimMember or Other

        The members of the team who provided the products and services.

        • extension
          required, Array of careTeamClaimScope or Other

          An Extension

        • sequence
          required, number

          A number to uniquely identify care team entries.

        • provider
          required, object

          Member of the team who provided the product or service.

          Must reference one of the following types of resources:

          • Practitioner
          • Organization
          • reference
            string

            A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

      • supportingInfo
        Array of AdmissionDates, DischargeDates, AdditionalInformation, MessageText or Other

        An array of supporting information for the claim. Each piece of information is is linked to a claim line item via sequence and its type is identified by category

          Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

        • sequence
          required, number

          A number to uniquely identify supporting information entries.

        • category
          required, object

          The general class of the information supplied: information; exception; accident, employment; onset, etc.

          • coding
            required, Array of object

            A reference to a code defined by a terminology system.

            • system
              required, string

              The identification of the code system that defines the meaning of the symbol in the code.

              Value: http://hl7.org/fhir/us/davinci-pas/CodeSystem/PASSupportingInfoType
            • code
              required, string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

              Value: admissionDates
          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

        • timingDate
          required, string

          The date when or period to which this information refers.

          Only one of timingDate, timingPeriod may be present.

        • timingPeriod
          required, object

          The date when or period to which this information refers.

          Only one of timingDate, timingPeriod may be present.

          • id
            string

            A sequence of Unicode characters

          • extension
            Array of object

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            • id
              string

              A sequence of Unicode characters

            • url
              string

              String of characters used to identify a name or a resource

            • valueBase64Binary
              string

              Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

          • start
            string

            A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

          • _start
            object

            Extensions for start

            • id
              string

              A sequence of Unicode characters

            • extension
              Array of object

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              • id
                string

                A sequence of Unicode characters

              • url
                string

                String of characters used to identify a name or a resource

              • valueBase64Binary
                string

                Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

          • end
            string

            A date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.

          • _end
            object

            Extensions for end

            • id
              string

              A sequence of Unicode characters

            • extension
              Array of object

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              • id
                string

                A sequence of Unicode characters

              • url
                string

                String of characters used to identify a name or a resource

              • valueBase64Binary
                string

                Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

      • diagnosis
        Array of object

        Information about diagnoses relevant to the claim items.

        • sequence
          required, number

          A number to uniquely identify diagnosis entries.

        • diagnosisCodeableConcept
          required, object

          The nature of illness or problem in a coded form or as a reference to an external defined Condition.

          • coding
            Array of object

            A reference to a code defined by a terminology system.

            • system
              string

              The identification of the code system that defines the meaning of the symbol in the code.

            • code
              string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      • accident
        object

        Details of an accident which resulted in injuries which required the products and services listed in the claim.

        • date
          required, string

          Date of an accident event related to the products and services contained in the claim.

        • type
          object

          The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

          • coding
            Array of object

            A reference to a code defined by a terminology system.

            • system
              string

              The identification of the code system that defines the meaning of the symbol in the code.

            • code
              string

              A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

          • text
            string

            A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Response fields and example

1
{}
  • resourceType
    required, string

    Identifies the type of the resource

    Value: Bundle
  • type
    required, string

    Indicates the purpose of this bundle - how it is intended to be used.

    Value: collection
  • timestamp
    required, string

    The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle.

  • entry
    required, Array of ClaimResponse, Patient, Coverage, Organization, PractitionerRole, Practitioner, RelatedPerson, Claim or Other

    An array of FHIR resources including the following:

    • ClaimResponse - the primary response resource
    • Patient - the patient the claim response is about
    • Organization - at least one resource representing the party responsible for making the claim. Additional organization resources may carry information such as pharmacy, payor, or policy holder.
    • Coverage - the patient's insurance

    The ClaimResponse is the only resource that must be present in the bundle. It references several other of the above resources which should already be known to the requesting system.

    However, some workflows may not always persist the information, so it is best practice for the responding system to preserve and re-include all referenced resources in the Claim Response bundle.

      An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).

    • resource
      required, object

      This resource provides the adjudication details from the processing of a Claim resource.

      • resourceType
        required, string

        Identifies the type of the resource

        Value: ClaimResponse
      • status
        required, string

        The status of the resource instance.

        Value: active
      • type
        required, object

        Type of claim. Example Codes

        For prescriptions, typically code='pharmacy' and system='http://terminology.hl7.org/CodeSystem/claim-type'

        • coding
          Array of object

          A reference to a code defined by a terminology system.

          • system
            string

            The identification of the code system that defines the meaning of the symbol in the code.

          • code
            string

            A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

        • text
          string

          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

      • use
        required, string

        A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

        Value: preauthorization
      • patient
        required, object

        The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

        Must be a resource of type Patient.

        • reference
          string

          A reference to a Patient resource

      • created
        required, string

        The date this resource was created.

      • insurer
        required, object

        The party responsible for authorization, adjudication and reimbursement.

        Must be a resource of type Organization.

        • reference
          string

          A reference to an Organization resource

      • outcome
        required, string

        The outcome of the claim, predetermination, or preauthoirization processing.

        queued | complete | error | partial

        Possible Values: queued, complete, error, partial
      • requestor
        object

        The provider which is responsible for the claim, predetermination or preauthorization.

        Must be a resource of type Organization.

        • reference
          string

          A reference to an Organization resource

      • request
        object

        A reference to the Claim resource triggering adjudication. This can be either the same identifier as the original Claim.identifier or else reference can point to the Claim.id value. When sending only the reference, it is helpful to also include the original Claim resource in the request.

        Must be a resource of type Claim.

        • reference
          string

          A reference to another resource. This is typically either a relative reference which includes the resource type and ID, or an internal reference which starts with # and refers to a contained resource.

        • identifier
          object

          An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

          • extension
            Array of Boolean, String, CodeableConcept, Coding, HumanName or Reference

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            • url
              required, string

              Source of the definition for the extension code - a logical name or a URL.

            • valueBoolean
              boolean

              A single value for the extension.

          • use
            string

            The purpose of this identifier.

            Possible Values: usual, official, temp, secondary, old (If known)
          • system
            string

            Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

          • value
            string

            The portion of the identifier typically relevant to the user and which is unique within the context of the system.

      • item
        Array of object

        A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

        • itemSequence
          required, number

          A number to uniquely reference the claim item entries.

        • adjudication
          required, Array of object

          If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

          • category
            required, object

            Type of adjudication information. Example Codes

            • coding
              required, Array of object

              A reference to a code defined by a terminology system.

              • system
                required, string

                The identification of the code system that defines the meaning of the symbol in the code.

                Value: http://terminology.hl7.org/CodeSystem/adjudication
              • code
                required, string

                A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

                Value: submitted
            • text
              string

              A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

          • extension
            Array of reviewAction or Other

            An Extension

              The details of the review action that is necessary for the authorization.

              See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction for more information

            • url
              required, string

              Source of the definition for the extension code - a logical name or a URL.

              Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
            • extension
              Array of code, number or Other

              Details of the review action that is necessary for the authorization, carried in sub-extension properties.

                The code describing the result of the review.

                See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode for more information

              • url
                required, string

                Source of the definition for the extension code - a logical name or a URL.

                Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionCode
              • valueCodeableConcept
                object

                Code indicating the type of action, from the X12 306 code set.

                • coding
                  Array of object

                  A reference to a code defined by a terminology system.

                  • system
                    string

                    The identification of the code system that defines the meaning of the symbol in the code.

                  • code
                    string

                    A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

                • text
                  string

                  A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

          • amount
            object

            Monetary amount associated with the category.

            • value
              number

              Numerical value (with implicit precision).

            • currency
              string

              ISO 4217 Currency Code (e.g. USD for US Dollar)

          • value
            number

            Non-monetary value. Used, for example, when the adjudication is a percentage.

        • extension
          Array of itemTraceNumber, preAuthIssueDate, preAuthPeriod, administrationReferenceNumber, authorizedItemDetail, communicatedDiagnosis or Other

          Additional information about the item

            Uniquely identifies this claim item. (2000F-TRN)

            See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber for more information

          • url
            required, string

            Source of the definition for the extension code - a logical name or a URL.

            Value: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemTraceNumber
          • valueIdentifier
            object

            Uniquely identifies this claim item

            • value
              string

              The portion of the identifier typically relevant to the user and which is unique within the context of the system.

      • processNote
        Array of object

        A note that describes or explains adjudication results in a human readable form.

        • text
          required, string

          The explanation or description associated with the processing.