0.1.0 - ci-build

kenyaClaimsIG - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: ClaimResponse

Official URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/ClaimResponse-ke Version: 0.1.0
Draft as of 2024-09-06 Computable Name: ClaimResponseProfile

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

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id S 1..1 id Unique string for reference purposes
... meta 1..1 Meta Metadata about the resource
.... profile 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... status S 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use S 1..1 code claim | preauthorization | predetermination
... patient S 1..1 Reference(SHAPatient) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement
... outcome S 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition S 0..1 string Disposition Message
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 0..* positiveInt Applicable note numbers
.... adjudication
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
.... detail
..... adjudication 1..* BackboneElement Detail level adjudication details
...... reason 1..1 CodeableConcept Explanation of adjudication outcome
...... amount 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... subDetail
...... adjudication S 1..1 Subdetail level adjudication details
... total
.... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example)
... processNote
.... type 0..1 code display | print | printoper
Binding: NoteType (required)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)
... error
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id SΣ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ 1..1 Reference(SHAPatient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition S 0..1 string Disposition Message
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
.... detail 0..* BackboneElement Adjudication for claim details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... adjudication 1..* BackboneElement Detail level 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.

...... amount 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... adjudication S 1..1 See adjudication (ClaimResponse) Subdetail level adjudication details
... processNote 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 code display | print | printoper
Binding: NoteType (required)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.item.detail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id SΣ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ 1..1 Reference(SHAPatient) The recipient of the products and services
... created SΣ 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)
... disposition S 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 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 S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
..... 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..* BackboneElement Detail level 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 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... 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 S 1..1 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: USCLSCodes (example): Allowable service and product codes.

.... 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: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: USCLSCodes (example): Allowable service and product codes.

..... 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: USCLSCodes (example): Allowable service and product codes.

...... 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 Σ 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)
.... 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)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance 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 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... 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.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ClaimResponse.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.item.detail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id S 1..1 id Unique string for reference purposes
... meta 1..1 Meta Metadata about the resource
.... profile 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... status S 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use S 1..1 code claim | preauthorization | predetermination
... patient S 1..1 Reference(SHAPatient) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement
... outcome S 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition S 0..1 string Disposition Message
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 0..* positiveInt Applicable note numbers
.... adjudication
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
.... detail
..... adjudication 1..* BackboneElement Detail level adjudication details
...... reason 1..1 CodeableConcept Explanation of adjudication outcome
...... amount 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... subDetail
...... adjudication S 1..1 Subdetail level adjudication details
... total
.... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example)
... processNote
.... type 0..1 code display | print | printoper
Binding: NoteType (required)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)
... error
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id SΣ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ 1..1 Reference(SHAPatient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition S 0..1 string Disposition Message
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
.... detail 0..* BackboneElement Adjudication for claim details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... adjudication 1..* BackboneElement Detail level 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.

...... amount 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... adjudication S 1..1 See adjudication (ClaimResponse) Subdetail level adjudication details
... processNote 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 0..1 code display | print | printoper
Binding: NoteType (required)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.item.detail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id SΣ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... batchIdentifier 0..1 Identifier Extension for Batch Identifier
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-identifier
.... batchNumber 0..1 string Extension for Batch Number
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-number
.... batchPeriod 0..1 string Extension for Batch Period
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/batch-period
.... diagnosisRelatedGroup 0..1 CodeableConcept Extension for Diagnosis Related Group
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/diagnosis-related-group
.... reissueReason 0..1 CodeableConcept ReissueReason
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/reissue-reason
.... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..1 Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ 1..1 Reference(SHAPatient) The recipient of the products and services
... created SΣ 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)
... disposition S 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType S 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item S 0..* BackboneElement 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.
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... adjudicationOutcome 0..1 CodeableConcept AdjudicationOutcome
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/adjudication-outcome
..... patientInvoice 0..1 Identifier Extension for Patient Invoice
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/patient-invoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... noteNumber S 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 S 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (required)
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (required)
..... 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..* BackboneElement Detail level 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 1..1 Money Monetary amount
...... value 1..1 decimal Non-monetary value
..... 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 S 1..1 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: USCLSCodes (example): Allowable service and product codes.

.... 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: ExampleProgramReasonCodes (example): Program specific reason codes.


.... 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: USCLSCodes (example): Allowable service and product codes.

..... 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: USCLSCodes (example): Allowable service and product codes.

...... 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 Σ 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)
.... 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)
.... text S 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (required)
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance 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 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... errorExtensionExpression 0..1 string ErrorExtensionExpression
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/error-extension-expression
.... 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.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
ClaimResponse.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome
from the FHIR Standard
ClaimResponse.payeeTyperequiredClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryrequiredAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonrequiredAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.item.detail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagerequiredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron