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
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about a 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
... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A unique identifier assigned to this claim response.
... status ?!Σ 1..1 code The status of the resource instance.
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 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.
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... 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.
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 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.
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 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 Σ 1..1 dateTime The date this resource was created.
... insurer Σ 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 Σ 1..1 Reference(Claim) Original request resource reference.
... outcome Σ 1..1 code The outcome of the claim, predetermination, or preauthorization processing.
Binding: ClaimProcessingCodes (required): The result of the claim 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.
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... 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.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
..... adjudication 1..* BackboneElement The adjudication results.
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount 0..1 Money Monetary amount associated with the category.
..... subDetail 0..* BackboneElement A sub-detail adjudication of a simple product or service.
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... 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.
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount 0..1 Money Monetary amount associated with the category.
... total Σ 0..* BackboneElement Categorized monetary totals for the adjudication.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 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.
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... processNote 0..* BackboneElement A note that describes or explains adjudication results in a human readable form.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 positiveInt A number to uniquely identify a note entry.
.... type 1..1 code The business purpose of the note text.
Binding: NoteType (required): The presentation types of notes.

.... 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.
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
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|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
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.item.detail.subDetail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.subDetail.adjudication.reasonexampleAdjudicationReasonCodes
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.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
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()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about a 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 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A unique identifier assigned to this claim response.
... status ?!Σ 1..1 code The status of the resource instance.
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 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.
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... 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.
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 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.
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 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 Σ 1..1 dateTime The date this resource was created.
... insurer Σ 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 Σ 1..1 Reference(Claim) Original request resource reference.
... outcome Σ 1..1 code The outcome of the claim, predetermination, or preauthorization processing.
Binding: ClaimProcessingCodes (required): The result of the claim 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.
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... 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.
.... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
..... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1 Money Monetary amount associated with the category.
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple 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
..... detailSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement The adjudication results.
...... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount 0..1 Money Monetary amount associated with the category.
...... value 0..1 decimal Non-monetary value
..... subDetail 0..* BackboneElement A sub-detail adjudication of a simple product or service.
...... 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 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.
....... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount 0..1 Money Monetary amount associated with the category.
....... value 0..1 decimal Non-monetary value
... 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 Categorized monetary totals for the 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
.... category Σ 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Monetary total amount associated with 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 A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
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 A note that describes or explains adjudication results in a human readable form.
.... 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 1..1 positiveInt A number to uniquely identify a note entry.
.... type 1..1 code The business purpose of the note text.
Binding: NoteType (required): The presentation types of notes.

.... 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.
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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.
.... 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 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.
.... businessArrangement 0..1 string Additional provider contract number
.... 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.
.... 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 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.
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|4.0.1
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|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
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.item.detail.subDetail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.subDetail.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.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
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 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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about a 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
... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A unique identifier assigned to this claim response.
... status ?!Σ 1..1 code The status of the resource instance.
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 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.
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... 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.
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 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.
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 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 Σ 1..1 dateTime The date this resource was created.
... insurer Σ 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 Σ 1..1 Reference(Claim) Original request resource reference.
... outcome Σ 1..1 code The outcome of the claim, predetermination, or preauthorization processing.
Binding: ClaimProcessingCodes (required): The result of the claim 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.
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... 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.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
..... adjudication 1..* BackboneElement The adjudication results.
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount 0..1 Money Monetary amount associated with the category.
..... subDetail 0..* BackboneElement A sub-detail adjudication of a simple product or service.
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... 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.
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount 0..1 Money Monetary amount associated with the category.
... total Σ 0..* BackboneElement Categorized monetary totals for the adjudication.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 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.
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... processNote 0..* BackboneElement A note that describes or explains adjudication results in a human readable form.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 positiveInt A number to uniquely identify a note entry.
.... type 1..1 code The business purpose of the note text.
Binding: NoteType (required): The presentation types of notes.

.... 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.
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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.
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
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|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
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.item.detail.subDetail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.subDetail.adjudication.reasonexampleAdjudicationReasonCodes
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.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
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()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 1..1 id Unique string for reference purposes
... meta Σ 1..1 Meta Metadata about a 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 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 Identifier A unique identifier assigned to this claim response.
... status ?!Σ 1..1 code The status of the resource instance.
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 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.
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... 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.
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 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.
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 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 Σ 1..1 dateTime The date this resource was created.
... insurer Σ 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 Σ 1..1 Reference(Claim) Original request resource reference.
... outcome Σ 1..1 code The outcome of the claim, predetermination, or preauthorization processing.
Binding: ClaimProcessingCodes (required): The result of the claim 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.
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... 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.
.... 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... 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.
..... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1 Money Monetary amount associated with the category.
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple 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
..... detailSequence 1..1 positiveInt A number to uniquely reference the claim detail entry.
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement The adjudication results.
...... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount 0..1 Money Monetary amount associated with the category.
...... value 0..1 decimal Non-monetary value
..... subDetail 0..* BackboneElement A sub-detail adjudication of a simple product or service.
...... 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 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.
....... 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 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason 0..1 CodeableConcept A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount 0..1 Money Monetary amount associated with the category.
....... value 0..1 decimal Non-monetary value
... 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 Categorized monetary totals for the 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
.... category Σ 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.
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Monetary total amount associated with 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 A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
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 A note that describes or explains adjudication results in a human readable form.
.... 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 1..1 positiveInt A number to uniquely identify a note entry.
.... type 1..1 code The business purpose of the note text.
Binding: NoteType (required): The presentation types of notes.

.... 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.
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... 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.
.... 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 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.
.... businessArrangement 0..1 string Additional provider contract number
.... 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.
.... 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 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.
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|4.0.1
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|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
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.item.detail.subDetail.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.detail.subDetail.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.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
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()

 

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