FHIR Implementation Guide for ABDM
4.0.0 - active
FHIR Implementation Guide for ABDM
4.0.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v4.0.0). See the Directory of published versions
| Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse | Version: 4.0.0 | |||
| Draft as of 2023-11-06 | Computable Name: ClaimResponse | |||
This profile represents application level adjudication outcomes, or an application level error, that occur as a result of processing a supplied Claim resource, which could be a functional corollary of a Claim, Predetermination, or Preauthorization.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse | ClaimResponse | |||
  type | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) | |
 patient | 1..1 | Reference(Patient) | The recipient of the products and services | |
| insurer | S | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |
| request | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| disposition | S | 0..1 | string | Disposition Message |
 item | S | 0..* | BackboneElement | Adjudication for claim line items |
  adjudication | ||||
  reason | 1..1 | CodeableConcept | Explanation of adjudication outcome | |
| addItem | ||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Program Code (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| detail | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| subDetail | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| total | S | 0..* | BackboneElement | Adjudication totals |
| insurance | S | 0..* | BackboneElement | Patient insurance information |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.type | extensible | ClaimType |
| ClaimResponse.addItem.productOrService | example | ProductorService |
| ClaimResponse.addItem.programCode | example | ProgramCode (a valid code from Program Code) |
| ClaimResponse.addItem.detail.productOrService | example | ProductorService |
| ClaimResponse.addItem.detail.subDetail.productOrService | example | ProductorService |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
 type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. |
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created | Σ | 1..1 | dateTime | Response creation date |
| insurer | SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |
| request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication |
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| disposition | S | 0..1 | string | Disposition Message |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |
| adjudication | 1..* | BackboneElement | Adjudication details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |
| total | SΣ | 0..* | BackboneElement | Adjudication totals |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
| amount | Σ | 1..1 | Money | Financial total for the category |
| insurance | S | 0..* | BackboneElement | Patient insurance information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Insurance instance identifier | |
| focal | 1..1 | boolean | Coverage to be used for adjudication | |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.status | required | FinancialResourceStatusCodes |
| ClaimResponse.type | extensible | ClaimType |
| ClaimResponse.use | required | Use |
| ClaimResponse.outcome | required | ClaimProcessingCodes |
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes |
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes |
| ClaimResponse.total.category | example | AdjudicationValueCodes |
| ClaimResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. | ||||
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
| created | Σ | 1..1 | dateTime | Response creation date | ||||
| insurer | SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |||||
| request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition | S | 0..1 | string | Disposition Message | ||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
| payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item | S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | BackboneElement | Adjudication details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount | 0..1 | Money | Monetary amount | |||||
| value | 0..1 | decimal | Non-monetary value | |||||
| detail | 0..* | BackboneElement | Adjudication for claim details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..* | positiveInt | Item sequence number | |||||
| detailSequence | 0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Program Code (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
 serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail | 0..* | BackboneElement | Insurer added line details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total | SΣ | 0..* | BackboneElement | Adjudication totals | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount | Σ | 1..1 | Money | Financial total for the category | ||||
| payment | 0..1 | BackboneElement | Payment Details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date | 0..1 | date | Expected date of payment | |||||
| amount | 1..1 | Money | Payable amount after adjustment | |||||
| identifier | 0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form | 0..1 | Attachment | Printed reference or actual form | |||||
| processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number | 0..1 | positiveInt | Note instance identifier | |||||
| type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text | 1..1 | string | Note explanatory text | |||||
| language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance | S | 0..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Insurance instance identifier | |||||
| focal | 1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage | S | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..1 | positiveInt | Item sequence number | |||||
| detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| ClaimResponse.language | preferred | CommonLanguages
| ||||
| ClaimResponse.status | required | FinancialResourceStatusCodes | ||||
| ClaimResponse.type | extensible | ClaimType | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodes | ||||
| ClaimResponse.use | required | Use | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodes | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codes | ||||
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
| ClaimResponse.addItem.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.programCode | example | ProgramCode (a valid code from Program Code) | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodes | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodes | ||||
| ClaimResponse.addItem.detail.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodes | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codes | ||||
| ClaimResponse.formCode | example | Form Codes | ||||
| ClaimResponse.processNote.type | required | NoteType | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
| ||||
| ClaimResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClaimResponse
Summary
Mandatory: 0 element (13 nested mandatory elements)
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | ClaimResponse | |||
| type | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) | |
| patient | 1..1 | Reference(Patient) | The recipient of the products and services | |
| insurer | S | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |
| request | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
| outcome | S | 1..1 | code | queued | complete | error | partial |
| disposition | S | 0..1 | string | Disposition Message |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| adjudication | ||||
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome | |
| addItem | ||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Program Code (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| detail | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| subDetail | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |
| coding | ||||
| system | 1..1 | uri | Identity of the terminology system | |
| code | 1..1 | code | Symbol in syntax defined by the system | |
| display | 1..1 | string | Representation defined by the system | |
| total | S | 0..* | BackboneElement | Adjudication totals |
| insurance | S | 0..* | BackboneElement | Patient insurance information |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.type | extensible | ClaimType |
| ClaimResponse.addItem.productOrService | example | ProductorService |
| ClaimResponse.addItem.programCode | example | ProgramCode (a valid code from Program Code) |
| ClaimResponse.addItem.detail.productOrService | example | ProductorService |
| ClaimResponse.addItem.detail.subDetail.productOrService | example | ProductorService |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) |
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. |
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
| created | Σ | 1..1 | dateTime | Response creation date |
| insurer | SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |
| request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication |
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| disposition | S | 0..1 | string | Disposition Message |
| item | S | 0..* | BackboneElement | Adjudication for claim line items |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |
| adjudication | 1..* | BackboneElement | Adjudication details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |
| total | SΣ | 0..* | BackboneElement | Adjudication totals |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. |
| amount | Σ | 1..1 | Money | Financial total for the category |
| insurance | S | 0..* | BackboneElement | Patient insurance information |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | 1..1 | positiveInt | Insurance instance identifier | |
| focal | 1..1 | boolean | Coverage to be used for adjudication | |
| coverage | S | 1..1 | Reference(Coverage) | Insurance information |
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
| error | S | 0..* | BackboneElement | Processing errors |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes. | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| ClaimResponse.status | required | FinancialResourceStatusCodes |
| ClaimResponse.type | extensible | ClaimType |
| ClaimResponse.use | required | Use |
| ClaimResponse.outcome | required | ClaimProcessingCodes |
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes |
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes |
| ClaimResponse.total.category | example | AdjudicationValueCodes |
| ClaimResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
| status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
| type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: Claim Type (extensible) | ||||
| subType | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode. | |||||
| use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. | ||||
| patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
| created | Σ | 1..1 | dateTime | Response creation date | ||||
| insurer | SΣ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
| requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |||||
| request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication | ||||
| outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| disposition | S | 0..1 | string | Disposition Message | ||||
| preAuthRef | 0..1 | string | Preauthorization reference | |||||
| preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
| payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed. | |||||
| item | S | 0..* | BackboneElement | Adjudication for claim line items | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | BackboneElement | Adjudication details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount | 0..1 | Money | Monetary amount | |||||
| value | 0..1 | decimal | Non-monetary value | |||||
| detail | 0..* | BackboneElement | Adjudication for claim details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..* | positiveInt | Item sequence number | |||||
| detailSequence | 0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |||||
| provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: Program Code (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| serviced[x] | 0..1 | Date or dates of service or product delivery | ||||||
| servicedDate | date | |||||||
| servicedPeriod | Period | |||||||
| location[x] | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept | CodeableConcept | |||||||
| locationAddress | Address | |||||||
| locationReference | Reference(Location) | |||||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| bodySite | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch. | |||||
| subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations. | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail | 0..* | BackboneElement | Insurer added line details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail | 0..* | BackboneElement | Insurer added line items | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ProductorService (example) | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
| display | Σ | 1..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity | 0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice | 0..1 | Money | Fee, charge or cost per item | |||||
| factor | 0..1 | decimal | Price scaling factor | |||||
| net | 0..1 | Money | Total item cost | |||||
| noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
| adjudication | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total | SΣ | 0..* | BackboneElement | Adjudication totals | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount | Σ | 1..1 | Money | Financial total for the category | ||||
| payment | 0..1 | BackboneElement | Payment Details | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date | 0..1 | date | Expected date of payment | |||||
| amount | 1..1 | Money | Payable amount after adjustment | |||||
| identifier | 0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes. | |||||
| form | 0..1 | Attachment | Printed reference or actual form | |||||
| processNote | 0..* | BackboneElement | Note concerning adjudication | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number | 0..1 | positiveInt | Note instance identifier | |||||
| type | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes. | |||||
| text | 1..1 | string | Note explanatory text | |||||
| language | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
| |||||
| communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance | S | 0..* | BackboneElement | Patient insurance information | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence | 1..1 | positiveInt | Insurance instance identifier | |||||
| focal | 1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage | S | 1..1 | Reference(Coverage) | Insurance information | ||||
| businessArrangement | 0..1 | string | Additional provider contract number | |||||
| claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
| error | S | 0..* | BackboneElement | Processing errors | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence | 0..1 | positiveInt | Item sequence number | |||||
| detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
| subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
| code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| ClaimResponse.language | preferred | CommonLanguages
| ||||
| ClaimResponse.status | required | FinancialResourceStatusCodes | ||||
| ClaimResponse.type | extensible | ClaimType | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodes | ||||
| ClaimResponse.use | required | Use | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodes | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codes | ||||
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes | ||||
| ClaimResponse.addItem.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.programCode | example | ProgramCode (a valid code from Program Code) | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodes | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodes | ||||
| ClaimResponse.addItem.detail.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | ProductorService | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodes | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodes | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codes | ||||
| ClaimResponse.formCode | example | Form Codes | ||||
| ClaimResponse.processNote.type | required | NoteType | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
| ||||
| ClaimResponse.error.code | example | Adjudication Error Codes |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClaimResponse
Summary
Mandatory: 0 element (13 nested mandatory elements)
Must-Support: 8 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron