2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

7.16 Resource Reversal - Content

This resource maintained by the Financial Management Work Group

This resource provides the request and response details for the request for which all actions are to be reversed or terminated.

7.16.1 Scope and Usage

The Reversal resource indicates the resource which is to be reversed and provides both supporting information for the reversal and whether the receiving system is permitted to retain a copy of the reversed resource.

The reversal is the formal request to cease processing an incomplete prior request or to reverse and/or nullify a complete prior request or information submission. When nullify=true then all copies of the original submission are to be purged, although audit logs may be retained. When Nullify=false a copy of the original request may be retained.

Todo

7.16.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Reversal DomainResourceReversal request
... identifier 0..*IdentifierBusiness Identifier
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible practitioner
... organization 0..1OrganizationResponsible organization
... request 0..1OralHealthClaim | PharmacyClaim | VisionClaim | ProfessionalClaim | InstitutionalClaim | SupportingDocumentationRequest reference
... response 0..1ClaimResponse | StatusResponseResponse reference
... payee 0..1ElementPayee
.... type 0..1CodingPayee Type
PayeeType (Example)
.... provider 0..1PractitionerProvider who is the payee
.... organization 0..1OrganizationOrganization who is the payee
.... person 0..1PatientOther person who is the payee
... coverage 1..1ElementInsurance or medical plan
.... sequence 1..1integerService instance
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Relationship (Example)
... nullify 1..1booleanNullify

UML Diagram

Reversal (DomainResource)The Response Business Identifieridentifier : Identifier 0..*The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when this resource was createdcreated : dateTime 0..1The Insurer who is target of the requesttarget : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientprovider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientorganization : Reference(Organization) 0..1Reference of resource to reverserequest : Reference(OralHealthClaim|PharmacyClaim| VisionClaim|ProfessionalClaim| InstitutionalClaim| SupportingDocumentation) 0..1Reference of response to resource to reverseresponse : Reference(ClaimResponse|StatusResponse) 0..1If true remove all history excluding auditnullify : boolean 1..1PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding 0..1 « (A code for the party to be reimbursed.PayeeType) »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference(Practitioner) 0..1The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference(Organization) 0..1The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference(Patient) 0..1CoverageA service line itemsequence : integer 1..1The instance number of the Coverage which is the focus for adjudication, that is the Coverage to which the claim is to be adjudicated againstfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberRelationship) »Payee information supplied for matching purposespayee0..1Financial instrument by which payment information for health carecoverage1..1

XML Template

<Reversal xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <request><!-- 0..1 Reference(OralHealthClaim|PharmacyClaim|VisionClaim|
   ProfessionalClaim|InstitutionalClaim|SupportingDocumentation) Request reference --></request>
 <response><!-- 0..1 Reference(ClaimResponse|StatusResponse) Response reference --></response>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Payee Type --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 1..1 Service instance -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
 </coverage>
 <nullify value="[boolean]"/><!-- 1..1 Nullify -->
</Reversal>

JSON Template

{doco
  "resourceType" : "Reversal",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(OralHealthClaim|PharmacyClaim|VisionClaim|
   ProfessionalClaim|InstitutionalClaim|SupportingDocumentation) }, // Request reference
  "response" : { Reference(ClaimResponse|StatusResponse) }, // Response reference
  "payee" : { // Payee
    "type" : { Coding }, // Payee Type
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "coverage" : { // R! Insurance or medical plan
    "sequence" : <integer>, // R! Service instance
    "focal" : <boolean>, // R! Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R! Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding } // R! Patient relationship to subscriber
  },
  "nullify" : <boolean> // R! Nullify
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Reversal DomainResourceReversal request
... identifier 0..*IdentifierBusiness Identifier
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible practitioner
... organization 0..1OrganizationResponsible organization
... request 0..1OralHealthClaim | PharmacyClaim | VisionClaim | ProfessionalClaim | InstitutionalClaim | SupportingDocumentationRequest reference
... response 0..1ClaimResponse | StatusResponseResponse reference
... payee 0..1ElementPayee
.... type 0..1CodingPayee Type
PayeeType (Example)
.... provider 0..1PractitionerProvider who is the payee
.... organization 0..1OrganizationOrganization who is the payee
.... person 0..1PatientOther person who is the payee
... coverage 1..1ElementInsurance or medical plan
.... sequence 1..1integerService instance
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Relationship (Example)
... nullify 1..1booleanNullify

UML Diagram

Reversal (DomainResource)The Response Business Identifieridentifier : Identifier 0..*The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when this resource was createdcreated : dateTime 0..1The Insurer who is target of the requesttarget : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientprovider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientorganization : Reference(Organization) 0..1Reference of resource to reverserequest : Reference(OralHealthClaim|PharmacyClaim| VisionClaim|ProfessionalClaim| InstitutionalClaim| SupportingDocumentation) 0..1Reference of response to resource to reverseresponse : Reference(ClaimResponse|StatusResponse) 0..1If true remove all history excluding auditnullify : boolean 1..1PayeeParty to be reimbursed: Subscriber, provider, othertype : Coding 0..1 « (A code for the party to be reimbursed.PayeeType) »The provider who is to be reimbursed for the claim (the party to whom any benefit is assigned)provider : Reference(Practitioner) 0..1The organization who is to be reimbursed for the claim (the party to whom any benefit is assigned)organization : Reference(Organization) 0..1The person other than the subscriber who is to be reimbursed for the claim (the party to whom any benefit is assigned)person : Reference(Patient) 0..1CoverageA service line itemsequence : integer 1..1The instance number of the Coverage which is the focus for adjudication, that is the Coverage to which the claim is to be adjudicated againstfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberRelationship) »Payee information supplied for matching purposespayee0..1Financial instrument by which payment information for health carecoverage1..1

XML Template

<Reversal xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <request><!-- 0..1 Reference(OralHealthClaim|PharmacyClaim|VisionClaim|
   ProfessionalClaim|InstitutionalClaim|SupportingDocumentation) Request reference --></request>
 <response><!-- 0..1 Reference(ClaimResponse|StatusResponse) Response reference --></response>
 <payee>  <!-- 0..1 Payee -->
  <type><!-- 0..1 Coding Payee Type --></type>
  <provider><!-- 0..1 Reference(Practitioner) Provider who is the payee --></provider>
  <organization><!-- 0..1 Reference(Organization) Organization who is the payee --></organization>
  <person><!-- 0..1 Reference(Patient) Other person who is the payee --></person>
 </payee>
 <coverage>  <!-- 1..1 Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 1..1 Service instance -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
 </coverage>
 <nullify value="[boolean]"/><!-- 1..1 Nullify -->
</Reversal>

JSON Template

{doco
  "resourceType" : "Reversal",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(OralHealthClaim|PharmacyClaim|VisionClaim|
   ProfessionalClaim|InstitutionalClaim|SupportingDocumentation) }, // Request reference
  "response" : { Reference(ClaimResponse|StatusResponse) }, // Response reference
  "payee" : { // Payee
    "type" : { Coding }, // Payee Type
    "provider" : { Reference(Practitioner) }, // Provider who is the payee
    "organization" : { Reference(Organization) }, // Organization who is the payee
    "person" : { Reference(Patient) } // Other person who is the payee
  },
  "coverage" : { // R! Insurance or medical plan
    "sequence" : <integer>, // R! Service instance
    "focal" : <boolean>, // R! Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R! Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding } // R! Patient relationship to subscriber
  },
  "nullify" : <boolean> // R! Nullify
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.16.2.1 Terminology Bindings

PathDefinitionTypeReference
Reversal.ruleset
Reversal.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset
Reversal.payee.type A code for the party to be reimbursed.Examplehttp://hl7.org/fhir/vs/payeetype
Reversal.coverage.relationship The code for the relationship of the patient to the subscriberExamplehttp://hl7.org/fhir/vs/relationship

7.16.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe business identifier of the EligibilityReversal.identifier