Da Vinci - Prior Authorization Support
0.1.0 - STU Ballot

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

StructureDefinition: PASClaimResponse

The official URL for this profile is: 

http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*
... extension-reviewAction S1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
... extension-reviewActionReason S0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
... extension-authorizedEventDate S0..1date, PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate
... identifier S0..*Identifier
... use S1..1codeFixed Value: preauthorization
... created S1..1dateTime
... insurer S1..1Reference(UMOOrganization)
... requestor S0..1Reference(RequestorPractitionerRole | RequestorOrganization)
... request S0..1Reference(PASClaim)
... outcome S1..1code
... preAuthPeriod S0..1Period
... item S0..*BackboneElement
.... extension-itemReference 0..*IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemReference
.... extension-reviewAction S1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
.... extension-reviewActionReason S0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
.... extension-itemPreAuthPeriod S0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-itemPreAuthIssueDate S0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... noteNumber S0..*positiveInt
... processNote S0..*BackboneElement
.... number S0..1positiveInt
.... text S1..1string
... communicationRequest S0..*Reference(CommunicationRequest)
... insurance S0..*BackboneElement
.... coverage S1..1Reference(Coverage)
... error S0..*BackboneElement
.... itemSequence S0..1positiveInt
.... code S1..1CodeableConcept

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse I0..*Response to a claim predetermination or preauthorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-reviewAction SI1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
... extension-reviewActionReason SI0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
... extension-authorizedEventDate SI0..1date, PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Fixed Value: preauthorization
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(UMOOrganization)Party responsible for reimbursement
... requestor S0..1Reference(RequestorPractitionerRole | RequestorOrganization)Party responsible for the claim
... request SΣ0..1Reference(PASClaim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example)
... item SI0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemReference I0..*IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemReference
.... extension-reviewAction SI1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
.... extension-reviewActionReason SI0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
.... extension-itemPreAuthPeriod SI0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-itemPreAuthIssueDate SI0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication I1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail I0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Detail level adjudication details
..... subDetail I0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*Unknown reference to #ClaimResponse.item.adjudication
Subdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(http://hl7.org/fhir/R4/location.html)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items adjudication
.... detail I0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
... adjudication 0..*Unknown reference to #ClaimResponse.item.adjudication
Header-level adjudication
... total ΣI0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
.... amount Σ1..1MoneyFinancial total for the category
... payment I0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form 0..1AttachmentPrinted reference or actual form
... processNote SI0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number S0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text S1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... communicationRequest S0..*Reference(CommunicationRequest)Request for additional information
... insurance SI0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error SI0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code S1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example)

doco Documentation for this format

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*
... extension-reviewAction S1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
... extension-reviewActionReason S0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
... extension-authorizedEventDate S0..1date, PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate
... identifier S0..*Identifier
... use S1..1codeFixed Value: preauthorization
... created S1..1dateTime
... insurer S1..1Reference(UMOOrganization)
... requestor S0..1Reference(RequestorPractitionerRole | RequestorOrganization)
... request S0..1Reference(PASClaim)
... outcome S1..1code
... preAuthPeriod S0..1Period
... item S0..*BackboneElement
.... extension-itemReference 0..*IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemReference
.... extension-reviewAction S1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
.... extension-reviewActionReason S0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
.... extension-itemPreAuthPeriod S0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-itemPreAuthIssueDate S0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... noteNumber S0..*positiveInt
... processNote S0..*BackboneElement
.... number S0..1positiveInt
.... text S1..1string
... communicationRequest S0..*Reference(CommunicationRequest)
... insurance S0..*BackboneElement
.... coverage S1..1Reference(Coverage)
... error S0..*BackboneElement
.... itemSequence S0..1positiveInt
.... code S1..1CodeableConcept

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse I0..*Response to a claim predetermination or preauthorization
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-reviewAction SI1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
... extension-reviewActionReason SI0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
... extension-authorizedEventDate SI0..1date, PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-authorizedEventDate
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier S0..*IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required)
... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible)
... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example)
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required)
Fixed Value: preauthorization
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(UMOOrganization)Party responsible for reimbursement
... requestor S0..1Reference(RequestorPractitionerRole | RequestorOrganization)Party responsible for the claim
... request SΣ0..1Reference(PASClaim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required)
... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example)
... item SI0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
.... extension-itemReference I0..*IdentifierExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemReference
.... extension-reviewAction SI1..1codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewAction
.... extension-reviewActionReason SI0..*codeExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-reviewActionReason
.... extension-itemPreAuthPeriod SI0..1PeriodExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthPeriod
.... extension-itemPreAuthIssueDate SI0..1dateExtension
URL: http://hl7.org/fhir/us/davinci-pas/StructureDefinition/extension-itemPreAuthIssueDate
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication I1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail I0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Detail level adjudication details
..... subDetail I0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*Unknown reference to #ClaimResponse.item.adjudication
Subdetail level adjudication details
... addItem I0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(http://hl7.org/fhir/R4/location.html)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items adjudication
.... detail I0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
..... subDetail I0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*Unknown reference to #ClaimResponse.item.adjudication
Added items detail adjudication
... adjudication 0..*Unknown reference to #ClaimResponse.item.adjudication
Header-level adjudication
... total ΣI0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example)
.... amount Σ1..1MoneyFinancial total for the category
... payment I0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example)
.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example)
... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example)
... form 0..1AttachmentPrinted reference or actual form
... processNote SI0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number S0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required)
.... text S1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... communicationRequest S0..*Reference(CommunicationRequest)Request for additional information
... insurance SI0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error SI0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code S1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example)

doco Documentation for this format

 

Other representations of profile: Schematron

Terminology Bindings

PathConformanceValueSet / Code
ClaimResponse.languagepreferredCommonLanguages
Max Binding: AllLanguages
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredFixed Value: preauthorization
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Max Binding: AllLanguages
ClaimResponse.error.codeexampleAdjudication Error Codes

Constraints

IdPathDetailsRequirements
dom-2ClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4ClaimResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3ClaimResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6ClaimResponseA resource should have narrative for robust management
: text.div.exists()
dom-5ClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
ele-1ClaimResponse.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.itemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.subDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.totalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.paymentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNoteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insuranceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.errorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())