Data population is similar to a typical predetermination ClaimResponse (where the corresponding Claim.use was set to “predetermination”), with the following key differences:

• in addition to cost and coverage for the requested medication and pharmacy, the responder may also return information about alternative medication + pharmacy combinations. These alternatives are conveyed in one or more ClaimResponse.addItem composites, characterized as independent options using an extension defined in this guide (isAlternative)
• the benefitRestriction extension is used to communicate the level at which the requested drug and pharmacy are covered, as well as alternative drug/pharmacy combinations (using high-level, pre-defined benefit restrictions tailored to the patient’s perspective)
• the processNote element can be used to communicate additional textual information related to the cost or coverage of the requested medication, pharmacy or alternative
• alternative pharmacies are communicated using referenced Organization resources
• certain other elements are fixed to values reflecting a medication-related request… ClaimResponse.type = “pharmacy” ClaimResponse.addItem elements are constrained to product identifiers and quantity units of measure describing medications.
  

In this profile, the ClaimResponse references the following supported resources, both of which are profiled in this guide:

• Patient (containing a small amount of identifying information to enable the insurer to locate the patient’s records)
• Organization (identifying an alternative pharmacy)
  
  

Must Support elements in this profile

Responding systems

• Responders SHOULD return pricing and coverage information for relevant drug/pharmacy alternatives, in the addItem composite

• Every response must contain either an item composite or an error composite, but not both. The Item composite MUST be populated when sufficient information is received to be able to answer the request. The error composite MUST be populated when the responder cannot complete processing due to insufficient or invalid information in the request

• The benefitRestrictions extension is a conditional element that MUST be populated when the responder is an insurer (or other processor representing the patient’s pharmacy benefit). It is not expected to be populated when the responder is a medication pricing source
• The processNote element is a conditional element that MAY be populated when the responder has additional information about costs or coverage related to an .item or .addItem. The noteNumber links an .item or .addItem to its associated processNote
• All elements marked Must Support are essential to communicating patient costs and coverage. The responder MUST ensure that content in these elements is accurate and complete

Client systems

• MUST be able to interpret and convey to users all cost and coverage information returned in the response, as appropriate to the application

• Text Summary
• Differential Table
• Snapshot Table
• Snapshot Table (Must Support)
• All

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	S	0..1	string	Unique ClaimResponse Resource Identifier
identifier	S	1..*	Identifier	RTPBC Response Identifier
value	S	1..1	string	Unique RTPBC response ID
status	S	1..1	code	Response status Fixed Value: active
type	S	1..1	CodeableConcept	Requested Service Type
coding	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	S	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	S	1..1	code	Processing Mode Fixed Value: predetermination
patient	S	1..1	Reference(RTPBC Patient)	Response Patient Information
insurer	S	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	Payer ID
request	S	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	RTPBC Request ID
outcome	S	1..1	code	Processing Outcome
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
rtpbc-benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
addItem	S	0..*	BackboneElement	Insurer added line items
rtpbc-isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
rtpbc-benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	S	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	S	1..1	decimal	Quantity in Billing Units
unit	S	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible)
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
processNote	S	0..*	BackboneElement	Determination Note
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Reject Code
display	S	1..1	string	Representation defined by the system
text	S	0..1	string	Reject Message
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	I	0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	SΣ	0..1	string	Unique ClaimResponse Resource Identifier
meta	ΣI	0..1	Meta	Metadata about the resource
implicitRules	?!ΣI	0..1	uri	A set of rules under which this content was created
language	I	0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!I	0..*	Extension	Extensions that cannot be ignored
identifier	SI	1..*	Identifier	RTPBC Response Identifier
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	Unique RTPBC response ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣI	1..1	code	Response status Binding: FinancialResourceStatusCodes (required) Fixed Value: active
type	SΣI	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣI	1..1	string	Representation defined by the system Fixed Value: Pharmacy
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	ΣI	0..1	string	Plain text representation of the concept
subType	I	0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example)
use	SΣI	1..1	code	Processing Mode Binding: Use (required) Fixed Value: predetermination
patient	SΣI	1..1	Reference(RTPBC Patient)	Response Patient Information
created	ΣI	1..1	dateTime	Response creation date
insurer	SΣI	1..1	Reference(Organization)	Party responsible for reimbursement
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣI	0..1	string	Literal reference, Relative, internal or absolute URL
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	SΣI	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	Payer ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣI	0..1	string	Text alternative for the resource
requestor	I	0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SΣI	1..1	Reference(Claim)	Submitter's RTPBC Request ID
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣI	0..1	string	Literal reference, Relative, internal or absolute URL
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	SΣI	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	RTPBC Request ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣI	0..1	string	Text alternative for the resource
outcome	SΣI	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required)
disposition	SI	0..1	string	Completed Note
preAuthRef	I	0..1	string	Preauthorization reference
preAuthPeriod	I	0..1	Period	Preauthorization reference effective period
payeeType	I	0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example)
item	SI	0..*	BackboneElement	Requested Product and Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Extension Slice: Unordered, Open by value:url
rtpbc-benefitRestriction	SI	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	SI	1..1	positiveInt	Claim item instance identifier
noteNumber	SI	0..*	positiveInt	Determination Note Number
adjudication	SI	1..*	BackboneElement	Requested Product and Pharmacy Determination
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SI	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
reason	I	0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount	SI	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Patient Pay Amount Value
currency	SΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
value	I	0..1	decimal	Non-monetary value
detail	I	0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	I	1..1	positiveInt	Claim detail instance identifier
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Detail level adjudication details
subDetail	I	0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence	I	1..1	positiveInt	Claim sub-detail instance identifier
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	0..*	See adjudication	Subdetail level adjudication details
addItem	SI	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Extension Slice: Unordered, Open by value:url
rtpbc-isAlternative	SI	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
rtpbc-benefitRestriction	SI	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	SI	1..*	positiveInt	Associated request Item Sequence
detailSequence	I	0..*	positiveInt	Detail sequence number
subdetailSequence	I	0..*	positiveInt	Subdetail sequence number
provider	SI	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣI	1..1	string	Reference to Priced Pharmacy
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	ΣI	0..1	Identifier	Logical reference, when literal reference is not known
display	ΣI	0..1	string	Text alternative for the resource
productOrService	SI	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Symbol in syntax defined by the system
display	SΣI	1..1	string	Product Description
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	ΣI	0..1	string	Plain text representation of the concept
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
programCode	I	0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
serviced[x]	I	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	I	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example)
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	SI	1..1	SimpleQuantity	Priced Quantity
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Quantity in Billing Units
unit	SΣI	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible)
system	ΣI	0..1	uri	System that defines coded unit form
code	ΣI	0..1	code	Coded form of the unit
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
bodySite	I	0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example)
subSite	I	0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example)
noteNumber	SI	0..*	positiveInt	Determination Note Number
adjudication	SI	1..*	BackboneElement	Alternative Product and Pharmacy Determination
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SI	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
reason	I	0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount	SI	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Patient Pay Amount Value
currency	SΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
value	I	0..1	decimal	Non-monetary value
detail	I	0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	I	1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
quantity	I	0..1	SimpleQuantity	Count of products or services
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Added items detail adjudication
subDetail	I	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	I	1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
quantity	I	0..1	SimpleQuantity	Count of products or services
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Added items detail adjudication
adjudication	I	0..*	See adjudication	Header-level adjudication
total	ΣI	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	ΣI	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example)
amount	ΣI	1..1	Money	Financial total for the category
payment	I	0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	I	1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example)
adjustment	I	0..1	Money	Payment adjustment for non-claim issues
adjustmentReason	I	0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example)
date	I	0..1	date	Expected date of payment
amount	I	1..1	Money	Payable amount after adjustment
identifier	I	0..1	Identifier	Business identifier for the payment
fundsReserve	I	0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example)
formCode	I	0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example)
form	I	0..1	Attachment	Printed reference or actual form
processNote	SI	0..*	BackboneElement	Determination Note
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	SI	1..1	positiveInt	Determination Note Number
type	I	0..1	code	display | print | printoper Binding: NoteType (required)
text	SI	1..1	string	Determination Note Text
language	I	0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages
communicationRequest	I	0..*	Reference(CommunicationRequest)	Request for additional information
insurance	I	0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	I	1..1	positiveInt	Insurance instance identifier
focal	I	1..1	boolean	Coverage to be used for adjudication
coverage	I	1..1	Reference(Coverage)	Insurance information
businessArrangement	I	0..1	string	Additional provider contract number
claimResponse	I	0..1	Reference(ClaimResponse)	Adjudication results
error	SI	0..*	BackboneElement	Error Information
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	I	0..1	positiveInt	Item sequence number
detailSequence	I	0..1	positiveInt	Detail sequence number
subDetailSequence	I	0..1	positiveInt	Subdetail sequence number
code	SI	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Reject Code
display	SΣI	1..1	string	Representation defined by the system
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	SΣI	0..1	string	Reject Message
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	I	0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	string	Unique ClaimResponse Resource Identifier
identifier	I	1..*	Identifier	RTPBC Response Identifier
value	ΣI	1..1	string	Unique RTPBC response ID
status	?!ΣI	1..1	code	Response status Binding: FinancialResourceStatusCodes (required) Fixed Value: active
type	ΣI	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible)
coding	ΣI	1..1	Coding	Code defined by a terminology system
system	ΣI	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	ΣI	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	ΣI	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	ΣI	1..1	code	Processing Mode Binding: Use (required) Fixed Value: predetermination
patient	ΣI	1..1	Reference(RTPBC Patient)	Response Patient Information
insurer	ΣI	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	ΣI	1..1	Identifier	Logical reference, when literal reference is not known
value	ΣI	1..1	string	Payer ID
request	ΣI	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	ΣI	1..1	Identifier	Logical reference, when literal reference is not known
value	ΣI	1..1	string	RTPBC Request ID
outcome	ΣI	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required)
disposition	I	0..1	string	Completed Note
item	I	0..*	BackboneElement	Requested Product and Pharmacy
rtpbc-benefitRestriction	I	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	I	1..1	positiveInt	Claim item instance identifier
noteNumber	I	0..*	positiveInt	Determination Note Number
adjudication	I	1..*	BackboneElement	Requested Product and Pharmacy Determination
category	I	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	I	1..1	Money	Patient Pay Component Amount
value	ΣI	1..1	decimal	Patient Pay Amount Value
currency	ΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
addItem	I	0..*	BackboneElement	Insurer added line items
rtpbc-isAlternative	I	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
rtpbc-benefitRestriction	I	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	I	1..*	positiveInt	Associated request Item Sequence
provider	I	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	ΣI	1..1	string	Reference to Priced Pharmacy
productOrService	I	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible)
coding	ΣI	1..*	Coding	Code defined by a terminology system
system	ΣI	1..1	uri	Identity of the terminology system
code	ΣI	1..1	code	Symbol in syntax defined by the system
display	ΣI	1..1	string	Product Description
quantity	I	1..1	SimpleQuantity	Priced Quantity
value	ΣI	1..1	decimal	Quantity in Billing Units
unit	ΣI	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible)
noteNumber	I	0..*	positiveInt	Determination Note Number
adjudication	I	1..*	BackboneElement	Alternative Product and Pharmacy Determination
category	I	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	I	1..1	Money	Patient Pay Component Amount
value	ΣI	1..1	decimal	Patient Pay Amount Value
currency	ΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
processNote	I	0..*	BackboneElement	Determination Note
number	I	1..1	positiveInt	Determination Note Number
text	I	1..1	string	Determination Note Text
error	I	0..*	BackboneElement	Error Information
code	I	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred)
coding	ΣI	1..*	Coding	Code defined by a terminology system
system	ΣI	1..1	uri	Identity of the terminology system
code	ΣI	1..1	code	Reject Code
display	ΣI	1..1	string	Representation defined by the system
text	ΣI	0..1	string	Reject Message
Documentation for this format

This structure is derived from ClaimResponse

Summary

Mandatory: 12 elements (23 nested mandatory elements)
Must-Support: 58 elements
Fixed Value: 5 elements

Structures

This structure refers to these other structures:

• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient
• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative

Differential View

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	S	0..1	string	Unique ClaimResponse Resource Identifier
identifier	S	1..*	Identifier	RTPBC Response Identifier
value	S	1..1	string	Unique RTPBC response ID
status	S	1..1	code	Response status Fixed Value: active
type	S	1..1	CodeableConcept	Requested Service Type
coding	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	S	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	S	1..1	code	Processing Mode Fixed Value: predetermination
patient	S	1..1	Reference(RTPBC Patient)	Response Patient Information
insurer	S	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	Payer ID
request	S	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	RTPBC Request ID
outcome	S	1..1	code	Processing Outcome
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
rtpbc-benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
addItem	S	0..*	BackboneElement	Insurer added line items
rtpbc-isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
rtpbc-benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	S	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	S	1..1	decimal	Quantity in Billing Units
unit	S	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible)
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
processNote	S	0..*	BackboneElement	Determination Note
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Reject Code
display	S	1..1	string	Representation defined by the system
text	S	0..1	string	Reject Message
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	I	0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	SΣ	0..1	string	Unique ClaimResponse Resource Identifier
meta	ΣI	0..1	Meta	Metadata about the resource
implicitRules	?!ΣI	0..1	uri	A set of rules under which this content was created
language	I	0..1	code	Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages
text	I	0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!I	0..*	Extension	Extensions that cannot be ignored
identifier	SI	1..*	Identifier	RTPBC Response Identifier
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	Unique RTPBC response ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣI	1..1	code	Response status Binding: FinancialResourceStatusCodes (required) Fixed Value: active
type	SΣI	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣI	1..1	string	Representation defined by the system Fixed Value: Pharmacy
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	ΣI	0..1	string	Plain text representation of the concept
subType	I	0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example)
use	SΣI	1..1	code	Processing Mode Binding: Use (required) Fixed Value: predetermination
patient	SΣI	1..1	Reference(RTPBC Patient)	Response Patient Information
created	ΣI	1..1	dateTime	Response creation date
insurer	SΣI	1..1	Reference(Organization)	Party responsible for reimbursement
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣI	0..1	string	Literal reference, Relative, internal or absolute URL
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	SΣI	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	Payer ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣI	0..1	string	Text alternative for the resource
requestor	I	0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SΣI	1..1	Reference(Claim)	Submitter's RTPBC Request ID
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣI	0..1	string	Literal reference, Relative, internal or absolute URL
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	SΣI	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!ΣI	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	ΣI	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible)
system	ΣI	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣI	1..1	string	RTPBC Request ID Example General: 123456
period	ΣI	0..1	Period	Time period when id is/was valid for use
assigner	ΣI	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣI	0..1	string	Text alternative for the resource
outcome	SΣI	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required)
disposition	SI	0..1	string	Completed Note
preAuthRef	I	0..1	string	Preauthorization reference
preAuthPeriod	I	0..1	Period	Preauthorization reference effective period
payeeType	I	0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example)
item	SI	0..*	BackboneElement	Requested Product and Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Extension Slice: Unordered, Open by value:url
rtpbc-benefitRestriction	SI	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	SI	1..1	positiveInt	Claim item instance identifier
noteNumber	SI	0..*	positiveInt	Determination Note Number
adjudication	SI	1..*	BackboneElement	Requested Product and Pharmacy Determination
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SI	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
reason	I	0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount	SI	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Patient Pay Amount Value
currency	SΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
value	I	0..1	decimal	Non-monetary value
detail	I	0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	I	1..1	positiveInt	Claim detail instance identifier
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Detail level adjudication details
subDetail	I	0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence	I	1..1	positiveInt	Claim sub-detail instance identifier
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	0..*	See adjudication	Subdetail level adjudication details
addItem	SI	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Extension Slice: Unordered, Open by value:url
rtpbc-isAlternative	SI	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
rtpbc-benefitRestriction	SI	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	SI	1..*	positiveInt	Associated request Item Sequence
detailSequence	I	0..*	positiveInt	Detail sequence number
subdetailSequence	I	0..*	positiveInt	Subdetail sequence number
provider	SI	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣI	1..1	string	Reference to Priced Pharmacy
type	ΣI	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible)
identifier	ΣI	0..1	Identifier	Logical reference, when literal reference is not known
display	ΣI	0..1	string	Text alternative for the resource
productOrService	SI	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Symbol in syntax defined by the system
display	SΣI	1..1	string	Product Description
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	ΣI	0..1	string	Plain text representation of the concept
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
programCode	I	0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example)
serviced[x]	I	0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]	I	0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example)
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity	SI	1..1	SimpleQuantity	Priced Quantity
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Quantity in Billing Units
unit	SΣI	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible)
system	ΣI	0..1	uri	System that defines coded unit form
code	ΣI	0..1	code	Coded form of the unit
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
bodySite	I	0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example)
subSite	I	0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example)
noteNumber	SI	0..*	positiveInt	Determination Note Number
adjudication	SI	1..*	BackboneElement	Alternative Product and Pharmacy Determination
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SI	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required)
reason	I	0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example)
amount	SI	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣI	1..1	decimal	Patient Pay Amount Value
currency	SΣI	1..1	code	Patient Pay Amount Currency Binding: Currencies (required)
value	I	0..1	decimal	Non-monetary value
detail	I	0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	I	1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
quantity	I	0..1	SimpleQuantity	Count of products or services
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Added items detail adjudication
subDetail	I	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService	I	1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example)
modifier	I	0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example)
quantity	I	0..1	SimpleQuantity	Count of products or services
unitPrice	I	0..1	Money	Fee, charge or cost per item
factor	I	0..1	decimal	Price scaling factor
net	I	0..1	Money	Total item cost
noteNumber	I	0..*	positiveInt	Applicable note numbers
adjudication	I	1..*	See adjudication	Added items detail adjudication
adjudication	I	0..*	See adjudication	Header-level adjudication
total	ΣI	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	ΣI	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example)
amount	ΣI	1..1	Money	Financial total for the category
payment	I	0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type	I	1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example)
adjustment	I	0..1	Money	Payment adjustment for non-claim issues
adjustmentReason	I	0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example)
date	I	0..1	date	Expected date of payment
amount	I	1..1	Money	Payable amount after adjustment
identifier	I	0..1	Identifier	Business identifier for the payment
fundsReserve	I	0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example)
formCode	I	0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example)
form	I	0..1	Attachment	Printed reference or actual form
processNote	SI	0..*	BackboneElement	Determination Note
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	SI	1..1	positiveInt	Determination Note Number
type	I	0..1	code	display | print | printoper Binding: NoteType (required)
text	SI	1..1	string	Determination Note Text
language	I	0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages
communicationRequest	I	0..*	Reference(CommunicationRequest)	Request for additional information
insurance	I	0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence	I	1..1	positiveInt	Insurance instance identifier
focal	I	1..1	boolean	Coverage to be used for adjudication
coverage	I	1..1	Reference(Coverage)	Insurance information
businessArrangement	I	0..1	string	Additional provider contract number
claimResponse	I	0..1	Reference(ClaimResponse)	Adjudication results
error	SI	0..*	BackboneElement	Error Information
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations
modifierExtension	?!ΣI	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	I	0..1	positiveInt	Item sequence number
detailSequence	I	0..1	positiveInt	Detail sequence number
subDetailSequence	I	0..1	positiveInt	Subdetail sequence number
code	SI	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred)
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣI	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension	I	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣI	1..1	uri	Identity of the terminology system
version	ΣI	0..1	string	Version of the system - if relevant
code	SΣI	1..1	code	Reject Code
display	SΣI	1..1	string	Representation defined by the system
userSelected	ΣI	0..1	boolean	If this coding was chosen directly by the user
text	SΣI	0..1	string	Reject Message
Documentation for this format