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: ClaimResponseAuthorizationResponseProfile

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

A response to a request for authorization or preauthorization of products and services.

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 1..1 id Unique string for reference purposes
... meta 1..1 Meta Metadata about a resource
.... profile 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Optional Extensions Element
Slice: Unordered, Open by value:url
.... 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
.... transferAuthorizationNumber 0..1 string TransferAuthorizationNumber
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/transfer-authorization-number
.... transferAuthorizationPeriod 0..1 Period TransferAuthorizationPeriod
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/transfer-authorization-period
.... transferAuthorizationProvider 0..1 Reference(SHAPractitioner | SHAOrganization) TransferAuthorizationProvider
URL: https://shr.tiberbuapps.com/fhir/StructureDefinition/transfer-authorization-provider
... status 1..1 code The status of the resource instance.
... type 1..1 CodeableConcept A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
... subType 0..1 CodeableConcept A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
... use 1..1 code A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
... patient 1..1 Reference(Patient) The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
... created 1..1 dateTime The date this resource was created.
... insurer 1..1 Reference(Organization) The party responsible for authorization, adjudication and reimbursement.
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) The provider which is responsible for the claim, predetermination or preauthorization.
... request 1..1 Reference(Claim) Original request resource reference.
... outcome 1..1 code The outcome of the claim, predetermination, or preauthorization processing.
... disposition 0..1 string A human readable description of the status of the adjudication.
... preAuthRef 0..1 string Reference from the Insurer which is used in later communications which refers to this adjudication.
... preAuthPeriod 0..1 Period The time frame during which this authorization is effective.
... payeeType 0..1 CodeableConcept Type of Party to be reimbursed: subscriber, provider, other.
... item 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
.... itemSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
.... noteNumber 0..* positiveInt The numbers associated with notes below which apply to the adjudication of this item.
.... adjudication 1..* BackboneElement If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
..... category 1..1 CodeableConcept If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
..... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
..... amount 0..1 Money Monetary amount associated with the category.
.... detail 0..* BackboneElement A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
..... detailSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
..... adjudication 1..* BackboneElement The adjudication results.
...... category 1..1 CodeableConcept A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
...... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
...... amount 0..1 Money Monetary amount associated with the category.
..... subDetail 0..* BackboneElement A sub-detail adjudication of a simple product or service.
...... subDetailSequence 1..1 positiveInt A number to uniquely reference the claim sub-detail entry.
...... noteNumber 0..* positiveInt The numbers associated with notes below which apply to the adjudication of this item.
...... adjudication 1..* BackboneElement The adjudication results.
....... category 1..1 CodeableConcept A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
....... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
....... amount 0..1 Money Monetary amount associated with the category.
... total 0..* BackboneElement Categorized monetary totals for the adjudication.
.... category 1..1 CodeableConcept A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
.... amount 1..1 Money Monetary total amount associated with the category.
... fundsReserve 0..1 CodeableConcept A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
... processNote 0..* BackboneElement A note that describes or explains adjudication results in a human readable form.
.... number 1..1 positiveInt A number to uniquely identify a note entry.
.... type 1..1 code The business purpose of the note text.
.... text 1..1 string The explanation or description associated with the processing.
.... language 0..1 CodeableConcept A code to define the language used in the text of the note.
... communicationRequest 0..1 Reference(CommunicationRequest) Request for additional supporting or authorizing information.
... insurance 0..* BackboneElement Financial instruments for reimbursement for the health care products and services specified on the claim.
.... sequence 1..1 positiveInt A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
.... focal 1..1 boolean A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
.... coverage 1..1 Reference(Coverage) Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
.... claimResponse 0..1 Reference(ClaimResponse) The result of the adjudication of the line items for the Coverage specified. This is used when an insurer is able to not just adjudicate the claim they were sent but also able to detect that they are the processor for the sebsequent claims and can adjudicate them too.
... error 0..* BackboneElement Errors encountered during the processing of the adjudication.
.... 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
.... itemSequence 0..1 positiveInt The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
.... detailSequence 0..1 positiveInt The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
.... subDetailSequence 0..1 positiveInt The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
.... code 1..1 CodeableConcept An error code, from a specified code system, which details why the claim could not be adjudicated.

doco Documentation for this format

 

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