R6 Ballot (2nd Draft)
FoundationPublish-box (todo)
| Financial Management Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Patient, Practitioner |
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#>
PREFIX rdf: <http://www.w3.org/1999/02/22-rdf-syntax-ns#>
IMPORT <code.shex>
IMPORT <date.shex>
IMPORT <Claim.shex>
IMPORT <Money.shex>
IMPORT <string.shex>
IMPORT <Period.shex>
IMPORT <Patient.shex>
IMPORT <decimal.shex>
IMPORT <boolean.shex>
IMPORT <Address.shex>
IMPORT <dateTime.shex>
IMPORT <Quantity.shex>
IMPORT <Coverage.shex>
IMPORT <Location.shex>
IMPORT <Reference.shex>
IMPORT <Encounter.shex>
IMPORT <Identifier.shex>
IMPORT <Attachment.shex>
IMPORT <positiveInt.shex>
IMPORT <Organization.shex>
IMPORT <Practitioner.shex>
IMPORT <DeviceRequest.shex>
IMPORT <SupplyRequest.shex>
IMPORT <DomainResource.shex>
IMPORT <NutritionOrder.shex>
IMPORT <ServiceRequest.shex>
IMPORT <CodeableConcept.shex>
IMPORT <BackboneElement.shex>
IMPORT <PractitionerRole.shex>
IMPORT <CodeableReference.shex>
IMPORT <MedicationRequest.shex>
IMPORT <VisionPrescription.shex>
IMPORT <CommunicationRequest.shex>
start=@<ClaimResponse> AND {fhir:nodeRole [fhir:treeRoot]}
# Response to a claim predetermination or preauthorization
<ClaimResponse> EXTENDS @<DomainResource> CLOSED {
a [fhir:ClaimResponse]?;
fhir:nodeRole [fhir:treeRoot]?;
fhir:identifier @<OneOrMore_Identifier>?; # Business Identifier for a claim
# response
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:status @<code> AND
{fhir:v @fhirvs:fm-status}; # active | cancelled | draft |
# entered-in-error
fhir:type @<CodeableConcept>; # More granular claim type
fhir:subType @<CodeableConcept>?; # More granular claim type
fhir:use @<code> AND
{fhir:v @fhirvs:claim-use}; # claim | preauthorization |
# predetermination
fhir:patient @<Reference> AND {fhir:link
@<Patient> ? }; # The recipient of the products and
# services
fhir:created @<dateTime>; # Response creation date
fhir:insurer @<Reference> AND {fhir:link
@<Organization> ? }?; # Party responsible for reimbursement
fhir:requestor @<Reference> AND {fhir:link
@<Organization> OR
@<Practitioner> OR
@<PractitionerRole> ? }?; # Party responsible for the claim
fhir:request @<Reference> AND {fhir:link
@<Claim> ? }?; # Id of resource triggering
# adjudication
fhir:outcome @<code> AND
{fhir:v @fhirvs:claim-outcome}; # queued | complete | error | partial
fhir:decision @<CodeableConcept>?; # Result of the adjudication
fhir:disposition @<string>?; # Disposition Message
fhir:preAuthRef @<string>?; # Preauthorization reference
fhir:preAuthPeriod @<Period>?; # Preauthorization reference
# effective period
fhir:event @<OneOrMore_ClaimResponse.event>?; # Event information
fhir:payeeType @<CodeableConcept>?; # Party to be paid any benefits
# payable
fhir:encounter @<OneOrMore_Reference_Encounter>?; # Encounters associated with the
# listed treatments
fhir:diagnosisRelatedGroup @<CodeableConcept>?; # Package billing code
fhir:item @<OneOrMore_ClaimResponse.item>?; # Adjudication for claim line items
fhir:addItem @<OneOrMore_ClaimResponse.addItem>?; # Insurer added line items
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Header-level adjudication
fhir:total @<OneOrMore_ClaimResponse.total>?; # Adjudication totals
fhir:payment @<ClaimResponse.payment>?; # Payment Details
fhir:fundsReserve @<CodeableConcept>?; # Funds reserved status
fhir:formCode @<CodeableConcept>?; # Printed form identifier
fhir:form @<Attachment>?; # Printed reference or actual form
fhir:processNote @<OneOrMore_ClaimResponse.processNote>?; # Note concerning adjudication
fhir:communicationRequest @<OneOrMore_Reference_CommunicationRequest>?; # Request for additional information
fhir:insurance @<OneOrMore_ClaimResponse.insurance>?; # Patient insurance information
fhir:error @<OneOrMore_ClaimResponse.error>?; # Processing errors
}
# Adjudication for claim details
<ClaimResponse.item.detail> EXTENDS @<BackboneElement> CLOSED {
fhir:detailSequence @<positiveInt>; # Claim detail instance identifier
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Detail level adjudication results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Detail level adjudication details
fhir:subDetail @<OneOrMore_ClaimResponse.item.detail.subDetail>?; # Adjudication for claim sub-details
}
# Adjudication totals
<ClaimResponse.total> EXTENDS @<BackboneElement> CLOSED {
fhir:category @<CodeableConcept>; # Type of adjudication information
fhir:amount @<Money>; # Financial total for the category
}
# Event information
<ClaimResponse.event> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>; # Specific event
fhir:when @<dateTime> OR
@<Period> ; # Occurance date or period
}
# Note concerning adjudication
<ClaimResponse.processNote> EXTENDS @<BackboneElement> CLOSED {
fhir:number @<positiveInt>?; # Note instance identifier
fhir:type @<CodeableConcept>?; # Note purpose
fhir:text @<string>; # Note explanatory text
fhir:language @<CodeableConcept>?; # Language of the text
}
# Adjudication details
<ClaimResponse.item.adjudication> EXTENDS @<BackboneElement> CLOSED {
fhir:category @<CodeableConcept>; # Type of adjudication information
fhir:reason @<CodeableConcept>?; # Explanation of adjudication outcome
fhir:amount @<Money>?; # Monetary amount
fhir:quantity @<Quantity>?; # Non-monetary value
}
# Adjudication for claim sub-details
<ClaimResponse.item.detail.subDetail> EXTENDS @<BackboneElement> CLOSED {
fhir:subDetailSequence @<positiveInt>; # Claim sub-detail instance
# identifier
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Subdetail level adjudication
# results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Subdetail level adjudication
# details
}
# Insurer added line details
<ClaimResponse.addItem.detail> EXTENDS @<BackboneElement> CLOSED {
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Added items detail level
# adjudication results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Added items detail adjudication
fhir:subDetail @<OneOrMore_ClaimResponse.addItem.detail.subDetail>?; # Insurer added line items
}
# Payment Details
<ClaimResponse.payment> EXTENDS @<BackboneElement> CLOSED {
fhir:type @<CodeableConcept>; # Partial or complete payment
fhir:adjustment @<Money>?; # Payment adjustment for non-claim
# issues
fhir:adjustmentReason @<CodeableConcept>?; # Explanation for the adjustment
fhir:date @<date>?; # Expected date of payment
fhir:amount @<Money>; # Payable amount after adjustment
fhir:identifier @<Identifier>?; # Business identifier for the payment
}
# Adjudication for claim line items
<ClaimResponse.item> EXTENDS @<BackboneElement> CLOSED {
fhir:itemSequence @<positiveInt>; # Claim item instance identifier
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Adjudication results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Adjudication details
fhir:detail @<OneOrMore_ClaimResponse.item.detail>?; # Adjudication for claim details
}
# Patient insurance information
<ClaimResponse.insurance> EXTENDS @<BackboneElement> CLOSED {
fhir:sequence @<positiveInt>; # Insurance instance identifier
fhir:focal @<boolean>; # Coverage to be used for
# adjudication
fhir:coverage @<Reference> AND {fhir:link
@<Coverage> ? }; # Insurance information
fhir:businessArrangement @<string>?; # Additional provider contract number
fhir:claimResponse @<Reference> AND {fhir:link
@<ClaimResponse> ? }?; # Adjudication results
}
# Adjudication results
<ClaimResponse.item.reviewOutcome> EXTENDS @<BackboneElement> CLOSED {
fhir:decision @<CodeableConcept>?; # Result of the adjudication
fhir:reason @<OneOrMore_CodeableConcept>?; # Reason for result of the
# adjudication
fhir:preAuthRef @<string>?; # Preauthorization reference
fhir:preAuthPeriod @<Period>?; # Preauthorization reference
# effective period
}
# Insurer added line items
<ClaimResponse.addItem> EXTENDS @<BackboneElement> CLOSED {
fhir:itemSequence @<OneOrMore_positiveInt>?; # Item sequence number
fhir:detailSequence @<OneOrMore_positiveInt>?; # Detail sequence number
fhir:subdetailSequence @<OneOrMore_positiveInt>?; # Subdetail sequence number
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:provider @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole>?; # Authorized providers
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:request @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>?; # Request or Referral for Service
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:programCode @<OneOrMore_CodeableConcept>?; # Program the product or service is
# provided under
fhir:serviced @<date> OR
@<Period> ?; # Date or dates of service or
# product delivery
fhir:location @<CodeableConcept> OR
@<Address> OR
(@<Reference> AND {fhir:link @<Location> }) ?; # Place of service or where product
# was supplied
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:bodySite @<OneOrMore_ClaimResponse.addItem.bodySite>?; # Anatomical location
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Added items adjudication results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Added items adjudication
fhir:detail @<OneOrMore_ClaimResponse.addItem.detail>?; # Insurer added line details
}
# Anatomical location
<ClaimResponse.addItem.bodySite> EXTENDS @<BackboneElement> CLOSED {
fhir:site @<OneOrMore_CodeableReference>; # Location
fhir:subSite @<OneOrMore_CodeableConcept>?; # Sub-location
}
# Processing errors
<ClaimResponse.error> EXTENDS @<BackboneElement> CLOSED {
fhir:itemSequence @<positiveInt>?; # Item sequence number
fhir:detailSequence @<positiveInt>?; # Detail sequence number
fhir:subDetailSequence @<positiveInt>?; # Subdetail sequence number
fhir:code @<CodeableConcept>; # Error code detailing processing
# issues
fhir:expression @<OneOrMore_string>?; # FHIRPath of element(s) related to
# issue
}
# Insurer added line items
<ClaimResponse.addItem.detail.subDetail> EXTENDS @<BackboneElement> CLOSED {
fhir:traceNumber @<OneOrMore_Identifier>?; # Number for tracking
fhir:revenue @<CodeableConcept>?; # Revenue or cost center code
fhir:productOrService @<CodeableConcept>?; # Billing, service, product, or drug
# code
fhir:productOrServiceEnd @<CodeableConcept>?; # End of a range of codes
fhir:modifier @<OneOrMore_CodeableConcept>?; # Service/Product billing modifiers
fhir:quantity @<Quantity>?; # Count of products or services
fhir:unitPrice @<Money>?; # Fee, charge or cost per item
fhir:factor @<decimal>?; # Price scaling factor
fhir:tax @<Money>?; # Total tax
fhir:net @<Money>?; # Total item cost
fhir:noteNumber @<OneOrMore_positiveInt>?; # Applicable note numbers
fhir:reviewOutcome @<ClaimResponse.item.reviewOutcome>?; # Added items subdetail level
# adjudication results
fhir:adjudication @<OneOrMore_ClaimResponse.item.adjudication>?; # Added items subdetail adjudication
}
#---------------------- Cardinality Types (OneOrMore) -------------------
<OneOrMore_Identifier> CLOSED {
rdf:first @<Identifier> ;
rdf:rest [rdf:nil] OR @<OneOrMore_Identifier>
}
<OneOrMore_ClaimResponse.event> CLOSED {
rdf:first @<ClaimResponse.event> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.event>
}
<OneOrMore_Reference_Encounter> CLOSED {
rdf:first @<Reference> AND {fhir:link
@<Encounter> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Encounter>
}
<OneOrMore_ClaimResponse.item> CLOSED {
rdf:first @<ClaimResponse.item> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.item>
}
<OneOrMore_ClaimResponse.addItem> CLOSED {
rdf:first @<ClaimResponse.addItem> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.addItem>
}
<OneOrMore_ClaimResponse.item.adjudication> CLOSED {
rdf:first @<ClaimResponse.item.adjudication> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.item.adjudication>
}
<OneOrMore_ClaimResponse.total> CLOSED {
rdf:first @<ClaimResponse.total> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.total>
}
<OneOrMore_ClaimResponse.processNote> CLOSED {
rdf:first @<ClaimResponse.processNote> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.processNote>
}
<OneOrMore_Reference_CommunicationRequest> CLOSED {
rdf:first @<Reference> AND {fhir:link
@<CommunicationRequest> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_CommunicationRequest>
}
<OneOrMore_ClaimResponse.insurance> CLOSED {
rdf:first @<ClaimResponse.insurance> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.insurance>
}
<OneOrMore_ClaimResponse.error> CLOSED {
rdf:first @<ClaimResponse.error> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.error>
}
<OneOrMore_positiveInt> CLOSED {
rdf:first @<positiveInt> ;
rdf:rest [rdf:nil] OR @<OneOrMore_positiveInt>
}
<OneOrMore_ClaimResponse.item.detail.subDetail> CLOSED {
rdf:first @<ClaimResponse.item.detail.subDetail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.item.detail.subDetail>
}
<OneOrMore_CodeableConcept> CLOSED {
rdf:first @<CodeableConcept> ;
rdf:rest [rdf:nil] OR @<OneOrMore_CodeableConcept>
}
<OneOrMore_ClaimResponse.addItem.detail.subDetail> CLOSED {
rdf:first @<ClaimResponse.addItem.detail.subDetail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.addItem.detail.subDetail>
}
<OneOrMore_ClaimResponse.item.detail> CLOSED {
rdf:first @<ClaimResponse.item.detail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.item.detail>
}
<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole> CLOSED {
rdf:first @<Reference> AND {fhir:link
@<Organization> OR
@<Practitioner> OR
@<PractitionerRole> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_Organization_OR_Practitioner_OR_PractitionerRole>
}
<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription> CLOSED {
rdf:first @<Reference> AND {fhir:link
@<DeviceRequest> OR
@<MedicationRequest> OR
@<NutritionOrder> OR
@<ServiceRequest> OR
@<SupplyRequest> OR
@<VisionPrescription> } ;
rdf:rest [rdf:nil] OR @<OneOrMore_Reference_DeviceRequest_OR_MedicationRequest_OR_NutritionOrder_OR_ServiceRequest_OR_SupplyRequest_OR_VisionPrescription>
}
<OneOrMore_ClaimResponse.addItem.bodySite> CLOSED {
rdf:first @<ClaimResponse.addItem.bodySite> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.addItem.bodySite>
}
<OneOrMore_ClaimResponse.addItem.detail> CLOSED {
rdf:first @<ClaimResponse.addItem.detail> ;
rdf:rest [rdf:nil] OR @<OneOrMore_ClaimResponse.addItem.detail>
}
<OneOrMore_CodeableReference> CLOSED {
rdf:first @<CodeableReference> ;
rdf:rest [rdf:nil] OR @<OneOrMore_CodeableReference>
}
<OneOrMore_string> CLOSED {
rdf:first @<string> ;
rdf:rest [rdf:nil] OR @<OneOrMore_string>
}
#---------------------- Value Sets ------------------------
# This value set includes Claim Processing Outcome codes.
fhirvs:claim-outcome ["queued" "complete" "error" "partial"]
# The purpose of the Claim: predetermination, preauthorization, claim.
fhirvs:claim-use ["claim" "preauthorization" "predetermination"]
# This value set includes Status codes.
fhirvs:fm-status ["active" "cancelled" "draft" "entered-in-error"]
Usage note: every effort has been made to ensure that the ShEx files are correct and useful, but they are not a normative part of the specification.
FHIR ®© HL7.org 2011+. FHIR R6 hl7.fhir.core#6.0.0-ballot2 generated on Mon, Aug 12, 2024 16:58+0800.
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