ClaimResponse - FHIR v5.0.0-snapshot3

Snapshot 3: Connectathon 32 Base

This page is part of the FHIR Specification (v5.0.0-snapshot3: R5 Snapshot #3, to support Connectathon 32). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

13.7.10 Resource ClaimResponse - R4/R5 Conversions

Financial Management icon

Work Group

Maturity Level: N/A

Standards Status: Informative

Security Category: Patient

Compartments: Patient, Practitioner

R4 : R5 Conversion maps for ClaimResponse.

Functional status for this map: 1 test that all execute ok. 1 fail round-trip testing and 1 r3 resources are invalid (0 errors). (see documentation)

13.7.10.1 R4 to R5

map "http://hl7.org/fhir/StructureMap/ClaimResponse3to4" = "R3 to R4 Conversions for ClaimResponse"

uses "http://hl7.org/fhir/3.0/StructureDefinition/ClaimResponse" alias ClaimResponseR3 as source
uses "http://hl7.org/fhir/StructureDefinition/ClaimResponse" alias ClaimResponse as target

imports "http://hl7.org/fhir/StructureMap/*3to4"

group ClaimResponse(source src : ClaimResponseR3, target tgt : ClaimResponse) extends DomainResource <<type+>> {
  src.identifier -> tgt.identifier;
  src.status -> tgt.status;
  src.type -> tgt.type;
  src.subType -> tgt.subType;
  src.use -> tgt.use;
  src.patient -> tgt.patient;
  src.created -> tgt.created;
  src.insurer -> tgt.insurer;
  src.requestProvider -> tgt.requestor;
  src.request -> tgt.request;
  src.outcome as vs then {
    vs.coding as c then {
      c.code where value in ('queued' | 'complete' | 'error' | 'partial') -> tgt.outcome;
    };
  };
  src.disposition -> tgt.disposition;
  src.payeeType -> tgt.payeeType;
  src.item as s -> tgt.item as t then ClaimResponseItem(s, t);
  src.addItem as s -> tgt.addItem as t then ClaimResponseAddItem(s, t);
  src.error as s -> tgt.error as t then ClaimResponseError(s, t);
  src.totalCost as s -> tgt.total as t then ClaimResponseTotalCost(s, t);
  src.totalBenefit as s -> tgt.total as t then ClaimResponseTotalBenefit(s, t);
  src.payment as s -> tgt.payment as t then ClaimResponsePayment(s, t);
  src.reserved as vs ->  tgt.fundsReserve as vt,  vt.coding = vs;
  src.form -> tgt.form;
  src.processNote as s -> tgt.processNote as t then ClaimResponseProcessNote(s, t);
  src.communicationRequest -> tgt.communicationRequest;
  src.insurance as s -> tgt.insurance as t then ClaimResponseInsurance(s, t);
}

group ClaimResponseItem(source src, target tgt) extends BackboneElement {
  src.sequenceLinkId -> tgt.itemSequence;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication as s -> tgt.adjudication as t then ClaimResponseItemAdjudication(s, t);
  src.detail as s -> tgt.detail as t then ClaimResponseItemDetail(s, t);
}

group ClaimResponseItemAdjudication(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.reason -> tgt.reason;
  src.amount -> tgt.amount;
  src.value -> tgt.value;
}

group ClaimResponseItemDetail(source src, target tgt) extends BackboneElement {
  src.detailSequence -> tgt.detailSequence;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ClaimResponseItemDetailSubDetail(s, t);
}

group ClaimResponseItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.subDetailSequence -> tgt.subDetailSequence;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ClaimResponseAddItem(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subdetailSequence -> tgt.subdetailSequence;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.detail as s -> tgt.detail as t then ClaimResponseAddItemDetail(s, t);
}

group ClaimResponseAddItemDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ClaimResponseAddItemDetailSubDetail(s, t);
}

group ClaimResponseAddItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ClaimResponseError(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subDetailSequence -> tgt.subDetailSequence;
  src.code -> tgt.code;
}

group ClaimResponsePayment(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.adjustment -> tgt.adjustment;
  src.adjustmentReason -> tgt.adjustmentReason;
  src.date -> tgt.date;
  src.amount -> tgt.amount;
  src.identifier -> tgt.identifier;
}

group ClaimResponseProcessNote(source src, target tgt) extends BackboneElement {
  src.number -> tgt.number;
  src.type -> tgt.type;
  src.text -> tgt.text;
  src.language -> tgt.language;
}

group ClaimResponseInsurance(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.focal -> tgt.focal;
  src.coverage -> tgt.coverage;
  src.businessArrangement -> tgt.businessArrangement;
  src.preAuthRef -> tgt.preAuthRef;
  src.claimResponse -> tgt.claimResponse;
}

group ClaimResponseTotalCost(source src, target tgt) extends BackboneElement {
  src ->  tgt.category as cc,  cc.text = 'Submitted Amount',  cc.coding as coding,  coding.code = 'submitted',  coding.system = 'http://terminology.hl7.org/CodeSystem/adjudication' "category";
  src as vs -> tgt.amount as vt then Money(vs, vt) "amount";
}

group ClaimResponseTotalBenefit(source src, target tgt) extends BackboneElement {
  src ->  tgt.category as cc,  cc.text = 'Benefit Amount',  cc.coding as coding,  coding.code = 'benefit',  coding.system = 'http://terminology.hl7.org/CodeSystem/adjudication' "amount";
  src as vs -> tgt.amount as vt then Money(vs, vt) "amount";
}

13.7.10.2 R5 to R4

map "http://hl7.org/fhir/StructureMap/ClaimResponse4to3" = "R4 to R3 Conversion for ClaimResponse"

uses "http://hl7.org/fhir/StructureDefinition/ClaimResponse" alias ClaimResponse as source
uses "http://hl7.org/fhir/3.0/StructureDefinition/ClaimResponse" alias ClaimResponseR3 as target

imports "http://hl7.org/fhir/StructureMap/*4to3"

group ClaimResponse(source src : ClaimResponse, target tgt : ClaimResponseR3) extends DomainResource <<type+>> {
  src.identifier -> tgt.identifier;
  src.status -> tgt.status;
  src.type -> tgt.type;
  src.subType -> tgt.subType;
  src.use -> tgt.use;
  src.patient -> tgt.patient;
  src.created -> tgt.created;
  src.insurer -> tgt.insurer;
  src.requestor -> tgt.requestProvider;
  src.request -> tgt.request;
  src.outcome as vs where value in ('complete' | 'error' | 'partial') ->  tgt.outcome as vt,  vt.coding as c,  c.system = 'http://hl7.org/fhir/remittance-outcome',  c.code = vs;
  src.disposition -> tgt.disposition;
  src.payeeType -> tgt.payeeType;
  src.item as s -> tgt.item as t then ClaimResponseItem(s, t);
  src.addItem as s -> tgt.addItem as t then ClaimResponseAddItem(s, t);
  src.error as s -> tgt.error as t then ClaimResponseError(s, t);
  src.total as total then {
    total.category as vs then {
      total.amount as va then {
        vs.coding as c where code = 'submitted' then {
          c -> tgt.totalCost as cost then Money(va, cost) "cost";
        };
      };
    };
  };
  src.total as total then {
    total.category as vs then {
      total.amount as va then {
        vs.coding as c where code = 'benefit' then {
          c -> tgt.totalBenefit as cost then Money(va, cost) "totalBenefit";
        };
      };
    };
  };
  src.payment as s -> tgt.payment as t then ClaimResponsePayment(s, t);
  src.fundsReserve as vs then {
    vs.coding -> tgt.reserved;
  };
  src.form -> tgt.form;
  src.processNote as s -> tgt.processNote as t then ClaimResponseProcessNote(s, t);
  src.communicationRequest -> tgt.communicationRequest;
  src.insurance as s -> tgt.insurance as t then ClaimResponseInsurance(s, t);
}

group ClaimResponseItem(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.sequenceLinkId;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication as s -> tgt.adjudication as t then ClaimResponseItemAdjudication(s, t);
  src.detail as s -> tgt.detail as t then ClaimResponseItemDetail(s, t);
}

group ClaimResponseItemAdjudication(source src, target tgt) extends BackboneElement {
  src.category -> tgt.category;
  src.reason -> tgt.reason;
  src.amount -> tgt.amount;
  src.value -> tgt.value;
}

group ClaimResponseItemDetail(source src, target tgt) extends BackboneElement {
  src.detailSequence -> tgt.detailSequence;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ClaimResponseItemDetailSubDetail(s, t);
}

group ClaimResponseItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.subDetailSequence -> tgt.subDetailSequence;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ClaimResponseAddItem(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subdetailSequence -> tgt.subdetailSequence;
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.serviced -> tgt.serviced;
  src.location -> tgt.location;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.bodySite -> tgt.bodySite;
  src.subSite -> tgt.subSite;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.detail as s -> tgt.detail as t then ClaimResponseAddItemDetail(s, t);
}

group ClaimResponseAddItemDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
  src.subDetail as s -> tgt.subDetail as t then ClaimResponseAddItemDetailSubDetail(s, t);
}

group ClaimResponseAddItemDetailSubDetail(source src, target tgt) extends BackboneElement {
  src.service -> tgt.service;
  src.modifier -> tgt.modifier;
  src.programCode -> tgt.programCode;
  src.quantity -> tgt.quantity;
  src.unitPrice -> tgt.unitPrice;
  src.factor -> tgt.factor;
  src.net -> tgt.net;
  src.noteNumber -> tgt.noteNumber;
  src.adjudication -> tgt.adjudication;
}

group ClaimResponseError(source src, target tgt) extends BackboneElement {
  src.itemSequence -> tgt.itemSequence;
  src.detailSequence -> tgt.detailSequence;
  src.subDetailSequence -> tgt.subDetailSequence;
  src.code -> tgt.code;
}

group ClaimResponsePayment(source src, target tgt) extends BackboneElement {
  src.type -> tgt.type;
  src.adjustment -> tgt.adjustment;
  src.adjustmentReason -> tgt.adjustmentReason;
  src.date -> tgt.date;
  src.amount -> tgt.amount;
  src.identifier -> tgt.identifier;
}

group ClaimResponseProcessNote(source src, target tgt) extends BackboneElement {
  src.number -> tgt.number;
  src.type -> tgt.type;
  src.text -> tgt.text;
  src.language -> tgt.language;
}

group ClaimResponseInsurance(source src, target tgt) extends BackboneElement {
  src.sequence -> tgt.sequence;
  src.focal -> tgt.focal;
  src.coverage -> tgt.coverage;
  src.businessArrangement -> tgt.businessArrangement;
  src.preAuthRef -> tgt.preAuthRef;
  src.claimResponse -> tgt.claimResponse;
}

13.7.10.3 R4 Validation Errors

<p>No validation errors - all conversions are clean</p>