Claimresponse.shex

ShEx statement for claimresponse

PREFIX fhir: <http://hl7.org/fhir/> 
PREFIX fhirvs: <http://hl7.org/fhir/ValueSet/>
PREFIX xsd: <http://www.w3.org/2001/XMLSchema#> 
BASE <http://hl7.org/fhir/shape/>

start=<ClaimResponse> AND {fhir:nodeRole [fhir:treeRoot]}


# Remittance resource
<ClaimResponse> CLOSED {
    a [fhir:ClaimResponse];
    fhir:nodeRole [fhir:treeRoot]?;
    fhir:Resource.id @<id>?;                # Logical id of this artifact
    fhir:Resource.meta @<Meta>?;            # Metadata about the resource
    fhir:Resource.implicitRules @<uri>?;    # A set of rules under which this 
                                            # content was created 
    fhir:Resource.language @<code>?;        # Language of the resource content
    fhir:DomainResource.text @<Narrative>?;  # Text summary of the resource, for 
                                            # human interpretation 
    fhir:DomainResource.contained @<Resource>*;  # Contained, inline Resources
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.identifier @<Identifier>*;  # Response  number
    fhir:ClaimResponse.status @<code> AND
    	{fhir:value @fhirvs:claimresponse-status};  # active | cancelled | draft | 
                                            # entered-in-error 
    (                                       # Id of resource triggering 
                                            # adjudication 
        fhir:ClaimResponse.requestIdentifier @<Identifier>  |
        fhir:ClaimResponse.requestReference @<ClaimReference> 
    )?;
    fhir:ClaimResponse.ruleset @<Coding>?;  # Resource version
    fhir:ClaimResponse.originalRuleset @<Coding>?;  # Original version
    fhir:ClaimResponse.created @<dateTime>?;  # Creation date
    (                                       # Insurer
        fhir:ClaimResponse.organizationIdentifier @<Identifier>  |
        fhir:ClaimResponse.organizationReference @<OrganizationReference> 
    )?;
    (                                       # Responsible practitioner
        fhir:ClaimResponse.requestProviderIdentifier @<Identifier>  |
        fhir:ClaimResponse.requestProviderReference @<PractitionerReference> 
    )?;
    (                                       # Responsible organization
        fhir:ClaimResponse.requestOrganizationIdentifier @<Identifier>  |
        fhir:ClaimResponse.requestOrganizationReference @<OrganizationReference> 
    )?;
    fhir:ClaimResponse.outcome @<Coding>?;  # complete | error | partial
    fhir:ClaimResponse.disposition @<string>?;  # Disposition Message
    fhir:ClaimResponse.payeeType @<Coding>?;  # Party to be paid any benefits 
                                            # payable 
    fhir:ClaimResponse.item @<ClaimResponse.item>*;  # Line items
    fhir:ClaimResponse.addItem @<ClaimResponse.addItem>*;  # Insurer added line items
    fhir:ClaimResponse.error @<ClaimResponse.error>*;  # Processing errors
    fhir:ClaimResponse.totalCost @<Money>?;  # Total Cost of service from the 
                                            # Claim 
    fhir:ClaimResponse.unallocDeductable @<Money>?;  # Unallocated deductible
    fhir:ClaimResponse.totalBenefit @<Money>?;  # Total benefit payable for the Claim
    fhir:ClaimResponse.payment @<ClaimResponse.payment>?; 
    fhir:ClaimResponse.reserved @<Coding>?;  # Funds reserved status
    fhir:ClaimResponse.form @<Coding> AND
    	{fhir:value @fhirvs:forms}?;  # Printed Form Identifier
    fhir:ClaimResponse.note @<ClaimResponse.note>*;  # Processing notes
    fhir:ClaimResponse.coverage @<ClaimResponse.coverage>*;  # Insurance or medical plan
    fhir:index xsd:integer?                 # Relative position in a list
}

# Processing notes
<ClaimResponse.note> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.note.number @<positiveInt>?;  # Note Number for this note
    fhir:ClaimResponse.note.type @<Coding> AND
    	{fhir:value @fhirvs:note-type}?;  # display | print | printoper
    fhir:ClaimResponse.note.text @<string>?;  # Note explanatory text
    fhir:ClaimResponse.note.language @<Coding>?;  # Language
    fhir:index xsd:integer?                 # Relative position in a list
}

# Insurer added line items
<ClaimResponse.addItem> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.addItem.sequenceLinkId @<positiveInt>*;  # Service instances
    fhir:ClaimResponse.addItem.revenue @<Coding>?;  # Revenue or cost center code
    fhir:ClaimResponse.addItem.category @<Coding>?;  # Type of service or product
    fhir:ClaimResponse.addItem.service @<Coding>?;  # Group, Service or Product
    fhir:ClaimResponse.addItem.modifier @<Coding>*;  # Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee @<Money>?;  # Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber @<positiveInt>*;  # List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication @<ClaimResponse.item.adjudication>*;  # Added items adjudication
    fhir:ClaimResponse.addItem.detail @<ClaimResponse.addItem.detail>*;  # Added items details
    fhir:index xsd:integer?                 # Relative position in a list
}

# Line items
<ClaimResponse.item> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.item.sequenceLinkId @<positiveInt>;  # Service instance
    fhir:ClaimResponse.item.noteNumber @<positiveInt>*;  # List of note numbers which apply
    fhir:ClaimResponse.item.adjudication @<ClaimResponse.item.adjudication>*;  # Adjudication details
    fhir:ClaimResponse.item.detail @<ClaimResponse.item.detail>*;  # Detail line items
    fhir:index xsd:integer?                 # Relative position in a list
}

# Processing errors
<ClaimResponse.error> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.error.sequenceLinkId @<positiveInt>?;  # Item sequence number
    fhir:ClaimResponse.error.detailSequenceLinkId @<positiveInt>?;  # Detail sequence number
    fhir:ClaimResponse.error.subdetailSequenceLinkId @<positiveInt>?;  # Subdetail sequence number
    fhir:ClaimResponse.error.code @<Coding>;  # Error code detailing processing 
                                            # issues 
    fhir:index xsd:integer?                 # Relative position in a list
}

# Insurance or medical plan
<ClaimResponse.coverage> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.coverage.sequence @<positiveInt>;  # Service instance identifier
    fhir:ClaimResponse.coverage.focal @<boolean>;  # Is the focal Coverage
    (                                       # Insurance information
        fhir:ClaimResponse.coverage.coverageIdentifier @<Identifier>  |
        fhir:ClaimResponse.coverage.coverageReference @<CoverageReference> 
    );
    fhir:ClaimResponse.coverage.businessArrangement @<string>?;  # Business agreement
    fhir:ClaimResponse.coverage.preAuthRef @<string>*;  # Pre-Authorization/Determination 
                                            # Reference 
    fhir:ClaimResponse.coverage.claimResponse @<ClaimResponseReference>?;  # Adjudication results
    fhir:index xsd:integer?                 # Relative position in a list
}

 
<ClaimResponse.payment> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.payment.type @<Coding>?;  # Partial or Complete
    fhir:ClaimResponse.payment.adjustment @<Money>?;  # Payment adjustment for non-Claim 
                                            # issues 
    fhir:ClaimResponse.payment.adjustmentReason @<Coding>?;  # Reason for Payment adjustment
    fhir:ClaimResponse.payment.date @<date>?;  # Expected data of Payment
    fhir:ClaimResponse.payment.amount @<Money>?;  # Payment amount
    fhir:ClaimResponse.payment.identifier @<Identifier>?;  # Payment identifier
    fhir:index xsd:integer?                 # Relative position in a list
}

# Detail line items
<ClaimResponse.item.detail> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.item.detail.sequenceLinkId @<positiveInt>;  # Service instance
    fhir:ClaimResponse.item.detail.noteNumber @<positiveInt>*;  # List of note numbers which apply
    fhir:ClaimResponse.item.detail.adjudication @<ClaimResponse.item.adjudication>*;  # Detail adjudication
    fhir:ClaimResponse.item.detail.subDetail @<ClaimResponse.item.detail.subDetail>*;  # Subdetail line items
    fhir:index xsd:integer?                 # Relative position in a list
}

# Added items details
<ClaimResponse.addItem.detail> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.addItem.detail.revenue @<Coding>?;  # Revenue or cost center code
    fhir:ClaimResponse.addItem.detail.category @<Coding>?;  # Type of service or product
    fhir:ClaimResponse.addItem.detail.service @<Coding>?;  # Service or Product
    fhir:ClaimResponse.addItem.detail.modifier @<Coding>*;  # Service/Product billing modifiers
    fhir:ClaimResponse.addItem.detail.fee @<Money>?;  # Professional fee or Product charge
    fhir:ClaimResponse.addItem.detail.noteNumber @<positiveInt>*;  # List of note numbers which apply
    fhir:ClaimResponse.addItem.detail.adjudication @<ClaimResponse.item.adjudication>*;  # Added items detail adjudication
    fhir:index xsd:integer?                 # Relative position in a list
}

# Adjudication details
<ClaimResponse.item.adjudication> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.item.adjudication.category @<Coding>;  # Adjudication category such as 
                                            # co-pay, eligible, benefit, etc. 
    fhir:ClaimResponse.item.adjudication.reason @<Coding>?;  # Adjudication reason
    fhir:ClaimResponse.item.adjudication.amount @<Money>?;  # Monetary amount
    fhir:ClaimResponse.item.adjudication.value @<decimal>?;  # Non-monetary value
    fhir:index xsd:integer?                 # Relative position in a list
}

# Subdetail line items
<ClaimResponse.item.detail.subDetail> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:modifierExtension @<Extension>*;   # Extensions that cannot be ignored
    fhir:ClaimResponse.item.detail.subDetail.sequenceLinkId @<positiveInt>;  # Service instance
    fhir:ClaimResponse.item.detail.subDetail.noteNumber @<positiveInt>*;  # List of note numbers which apply
    fhir:ClaimResponse.item.detail.subDetail.adjudication @<ClaimResponse.item.adjudication>*;  # Subdetail adjudication
    fhir:index xsd:integer?                 # Relative position in a list
}

#---------------------- Data Types -------------------

# Primitive Type dateTime
<dateTime> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:gYear OR xsd:gYearMonth OR xsd:date OR xsd:dateTime?;  # Primitive value for dateTime
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type date
<date> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:gYear OR xsd:gYearMonth OR xsd:date?;  # Primitive value for date
    fhir:index xsd:integer?                 # Relative position in a list
}

# Metadata about a resource
<Meta> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Meta.versionId @<id>?;             # Version specific identifier
    fhir:Meta.lastUpdated @<instant>?;      # When the resource version last 
                                            # changed 
    fhir:Meta.profile @<uri>*;              # Profiles this resource claims to 
                                            # conform to 
    fhir:Meta.security @<Coding>*;          # Security Labels applied to this 
                                            # resource 
    fhir:Meta.tag @<Coding>*;               # Tags applied to this resource
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type code
<code> CLOSED {
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:string?;                 # Primitive value for code
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type string
<string> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:string MAXLENGTH 1048576?;  # Primitive value for string
    fhir:index xsd:integer?                 # Relative position in a list
}

# Base Resource
<Resource> {a .+;
    fhir:Resource.id @<id>?;                # Logical id of this artifact
    fhir:Resource.meta @<Meta>?;            # Metadata about the resource
    fhir:Resource.implicitRules @<uri>?;    # A set of rules under which this 
                                            # content was created 
    fhir:Resource.language @<code>?;        # Language of the resource content
    fhir:index xsd:integer?
}

# Primitive Type uri
<uri> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:string?;                 # Primitive value for uri
    fhir:index xsd:integer?                 # Relative position in a list
}

<Extension> {fhir:extension @<Extension>*;
    fhir:index xsd:integer?
}

# An amount of economic utility in some recognised currency
<Money> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Quantity.value @<decimal>?;        # Numerical value (with implicit 
                                            # precision) 
    fhir:Quantity.comparator @<code> AND
    	{fhir:value @fhirvs:quantity-comparator}?;  # < | <= | >= | > - how to 
                                            # understand the value 
    fhir:Quantity.unit @<string>?;          # Unit representation
    fhir:Quantity.system @<uri>?;           # System that defines coded unit form
    fhir:Quantity.code @<code>?;            # Coded form of the unit
    fhir:index xsd:integer?                 # Relative position in a list
}

# An identifier intended for computation
<Identifier> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Identifier.use @<code> AND
    	{fhir:value @fhirvs:identifier-use}?;  # usual | official | temp | 
                                            # secondary (If known) 
    fhir:Identifier.type @<CodeableConcept>?;  # Description of identifier
    fhir:Identifier.system @<uri>?;         # The namespace for the identifier
    fhir:Identifier.value @<string>?;       # The value that is unique
    fhir:Identifier.period @<Period>?;      # Time period when id is/was valid 
                                            # for use 
    fhir:Identifier.assigner @<OrganizationReference>?;  # Organization that issued id (may 
                                            # be just text) 
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type boolean
<boolean> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:boolean?;                # Primitive value for boolean
    fhir:index xsd:integer?                 # Relative position in a list
}

# A human-readable formatted text, including images
<Narrative> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Narrative.status @<code> AND
    	{fhir:value @fhirvs:narrative-status};  # generated | extensions | 
                                            # additional | empty 
    fhir:Narrative.div xsd:string;          # Limited xhtml content
    fhir:index xsd:integer?                 # Relative position in a list
}

# A reference to a code defined by a terminology system
<Coding> CLOSED {
    fhir:concept IRI?;
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Coding.system @<uri>?;             # Identity of the terminology system
    fhir:Coding.version @<string>?;         # Version of the system - if relevant
    fhir:Coding.code @<code>?;              # Symbol in syntax defined by the 
                                            # system 
    fhir:Coding.display @<string>?;         # Representation defined by the 
                                            # system 
    fhir:Coding.userSelected @<boolean>?;   # If this coding was chosen directly 
                                            # by the user 
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type id
<id> CLOSED {
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:string?;                 # Primitive value for id
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type positiveInt
<positiveInt> CLOSED {
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:positiveInteger?;        # Primitive value for positiveInt
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type decimal
<decimal> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:decimal?;                # Primitive value for decimal
    fhir:index xsd:integer?                 # Relative position in a list
}

# Time range defined by start and end date/time
<Period> CLOSED {
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:Period.start @<dateTime>?;         # Starting time with inclusive 
                                            # boundary 
    fhir:Period.end @<dateTime>?;           # End time with inclusive boundary, 
                                            # if not ongoing 
    fhir:index xsd:integer?                 # Relative position in a list
}

# Primitive Type instant
<instant> CLOSED {
    fhir:id @<id>?;                         # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:value xsd:dateTime?;               # Primitive value for instant
    fhir:index xsd:integer?                 # Relative position in a list
}

# Concept - reference to a terminology or just  text
<CodeableConcept> CLOSED {
    fhir:concept IRI*;
    fhir:Element.id @<string>?;             # xml:id (or equivalent in JSON)
    fhir:extension @<Extension>*;           # Additional Content defined by 
                                            # implementations 
    fhir:CodeableConcept.coding @<Coding>*;  # Code defined by a terminology 
                                            # system 
    fhir:CodeableConcept.text @<string>?;   # Plain text representation of the 
                                            # concept 
    fhir:index xsd:integer?                 # Relative position in a list
}

#---------------------- Reference Types -------------------

<PractitionerReference> CLOSED {
    fhir:Element.id @<id>?;
    fhir:extension @<Extension>*;
    fhir:link @<Practitioner> OR CLOSED {a fhir:Practitioner}?;
    fhir:Reference.reference @<string>?;
    fhir:Reference.display @<string>?;
    fhir:index xsd:integer?
}

<OrganizationReference> CLOSED {
    fhir:Element.id @<id>?;
    fhir:extension @<Extension>*;
    fhir:link @<Organization> OR CLOSED {a fhir:Organization}?;
    fhir:Reference.reference @<string>?;
    fhir:Reference.display @<string>?;
    fhir:index xsd:integer?
}

<ClaimResponseReference> CLOSED {
    fhir:Element.id @<id>?;
    fhir:extension @<Extension>*;
    fhir:link @<ClaimResponse> OR CLOSED {a fhir:ClaimResponse}?;
    fhir:Reference.reference @<string>?;
    fhir:Reference.display @<string>?;
    fhir:index xsd:integer?
}

<CoverageReference> CLOSED {
    fhir:Element.id @<id>?;
    fhir:extension @<Extension>*;
    fhir:link @<Coverage> OR CLOSED {a fhir:Coverage}?;
    fhir:Reference.reference @<string>?;
    fhir:Reference.display @<string>?;
    fhir:index xsd:integer?
}

<ClaimReference> CLOSED {
    fhir:Element.id @<id>?;
    fhir:extension @<Extension>*;
    fhir:link @<Claim> OR CLOSED {a fhir:Claim}?;
    fhir:Reference.reference @<string>?;
    fhir:Reference.display @<string>?;
    fhir:index xsd:integer?
}

#---------------------- Value Sets ------------------------

# This value set includes a sample set of Forms codes.
@fhirvs:forms = ["1" "2"]

# A code specifying the state of the resource instance.
@fhirvs:claimresponse-status = ["active" "cancelled" "draft" "entered-in-error"]

# How the Quantity should be understood and represented.
@fhirvs:quantity-comparator = ["<" "<=" ">=" ">"]

# The status of a resource narrative
@fhirvs:narrative-status = ["generated" "extensions" "additional" "empty"]

# The presentation types of notes.
@fhirvs:note-type = ["display" "print" "printoper"]

# Identifies the purpose for this identifier, if known .
@fhirvs:identifier-use = ["usual" "official" "temp" "secondary"]