Claim $submit-preauthorization

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

  and 6 more...

  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.

  Any of: ClaimPatientMedicationRequestServiceRequestCoverageOrganizationPractitionerRolePractitionerRelatedPersonDocumentReferenceOther
  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.

      Any of: itemTraceNumberadministrationReferenceNumberrequestedServiceOther
      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.

          Any of: PrecisionOther
          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.

    Any of: OverallClaimMemberItemClaimMemberOther
    extension
    required, Array of careTeamClaimScope or Other
    An Extension
    Any of: careTeamClaimScopeOther
    A flag that indicates whether the care team applies to the entire claim or a single item.
    See http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-careTeamClaimScope 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-careTeamClaimScope
    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

    and 0 more...

    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

    Any of: AdmissionDatesDischargeDatesAdditionalInformationMessageTextOther
    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.