Da Vinci Prior Authorization Support (PAS) FHIR IG
2.1.0 - STU 2.1 United States of America flag

This page is part of the Da Vinci Prior Authorization Support (PAS) FHIR IG (v2.1.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: PASClaimInquiryResponse - Detailed Descriptions

Page standards status: Trial-use Maturity Level: 3

Definitions for the profile-claiminquiryresponse resource profile.

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
ShortResponse to a preauthorization query
2. ClaimResponse.item
4. ClaimResponse.item.extension:communicatedDiagnosis
Slice NamecommunicatedDiagnosis
ShortA code representing the diagnosis that is relevant to the preauthorization.
Control0..1
TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
Must Supporttrue

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

ShortResponse to a preauthorization queryResponse to a claim predetermination or preauthorization
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If 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-4: If 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-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. ClaimResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. ClaimResponse.identifier
Definition

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.


A unique identifier assigned to this claim response.

ShortAn identifier intended for computationBusiness Identifier for a claim response
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
This element is affected by the following invariants: ele-1
TypeIdentifier(PAS Identifier)
Is Modifierfalse
Must Supporttrue
Requirements

Allows claim responses to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.identifier.extension:subDepartment
Slice NamesubDepartment
Definition

An additional element that provides a further subdivision within the organization granting the identifier.

ShortExtension
Control0..1
TypeExtension(IdentifierSubDepartment) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. ClaimResponse.identifier.extension:jurisdiction
Slice Namejurisdiction
Definition

An additional element that provides the assigning jurisdiction of the identifier (i.e. provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.

ShortExtension
Control0..1
TypeExtension(IdentifierJurisdiction) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. ClaimResponse.identifier.use
Definition

The purpose of this identifier.

Shortusual | official | temp | secondary | old (If known)
Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control0..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ClaimResponse.identifier.system
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

ShortShould use a scheme of 'urn:trnorg:<TRN03>'The namespace for the identifier value
Comments

Identifier.system is always case sensitive.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ClaimResponse.identifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

ShortThe value that is unique
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Example<br/><b>General</b>:123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. ClaimResponse.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Pattern Valueactive
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.type
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ClaimResponse.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Claim, preauthorization, predetermination.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

This element is required to understand the nature of the request for adjudication.

Pattern Valuepreauthorization
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ClaimResponse.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

ShortThe recipient of the products and services
Control1..1
TypeReference(PAS Beneficiary Patient, Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ClaimResponse.created
Definition

The date this resource was created.

ShortResponse creation date
Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortParty responsible for reimbursement
Control1..1
TypeReference(PAS Insurer Organization, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ClaimResponse.requestor
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

ShortParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control0..1
TypeReference(PAS Requestor Organization, PAS PractitionerRole, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ClaimResponse.request
Definition

Original request resource reference.

ShortId of resource triggering adjudication
Control10..1
TypeReference(PAS Claim, Claim)
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ClaimResponse.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Shortqueued | complete | error | partial
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

The result of the claim processing.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. ClaimResponse.preAuthPeriod
Definition

The time frame during which this authorization is effective.

ShortPreauthorization reference effective period
Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ClaimResponse.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

ShortAdjudication for claim line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The adjudication for items provided on the claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ClaimResponse.item.extension:itemTraceNumber
Slice NameitemTraceNumber
Definition

Uniquely identifies this claim item. (2000F-TRN)

ShortUniquely identifies this claim item. (2000F-TRN)
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
42. ClaimResponse.item.extension:preAuthIssueDate
Slice NamepreAuthIssueDate
Definition

The date when this item's preauthorization was issued.

ShortThe date when this item's preauthorization was issued.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. ClaimResponse.item.extension:preAuthPeriod
Slice NamepreAuthPeriod
Definition

The date/period when this item's preauthorization is valid.

ShortThe date/period when this item's preauthorization is valid.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. ClaimResponse.item.extension:previousAuthorizationNumber
Slice NamepreviousAuthorizationNumber
Definition

A string assigned by the UMO to an authorized review outcome associated with this service item.

ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AuthorizationNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
48. ClaimResponse.item.extension:administrationReferenceNumber
Slice NameadministrationReferenceNumber
Definition

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
50. ClaimResponse.item.extension:requestedServiceDate
Slice NamerequestedServiceDate
Definition

The original date/period that was requested by the submitter for this item.

ShortThe original date/period that was requested by the submitter for this item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemRequestedServiceDate) (Extension Type: Choice of: dateTime, Period)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. ClaimResponse.item.extension:authorizedProvider
Slice NameauthorizedProvider
Definition

The specific provider who has been authorized to provide this item.

ShortThe specific provider who has been authorized to provide this item.
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemAuthorizedProvider) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
54. ClaimResponse.item.extension:authorizedItemDetail
Slice NameauthorizedItemDetail
Definition

The details of what has been authorized for this item.

ShortThe details of what has been authorized for this item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemAuthorizedDetail) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
56. ClaimResponse.item.extension:communicatedDiagnosis
Slice NamecommunicatedDiagnosis
Definition

A code representing the diagnosis that is the subject of the communication

ShortA code representing the diagnosis that is relevant to the preauthorization.
Control0..1
TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
58. ClaimResponse.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
60. ClaimResponse.item.itemSequence
Definition

A number to uniquely reference the claim item entries.

ShortClaim item instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. ClaimResponse.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

ShortAdjudication details
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. ClaimResponse.item.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. ClaimResponse.item.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
68. ClaimResponse.item.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. ClaimResponse.addItem
Definition

The first-tier service adjudications for payor added product or service lines.

ShortInsurer added line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. ClaimResponse.addItem.extension:itemTraceNumber
Slice NameitemTraceNumber
Definition

Uniquely identifies this claim item. (2000F-TRN)

ShortExtension
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
74. ClaimResponse.addItem.extension:preAuthIssueDate
Slice NamepreAuthIssueDate
Definition

The date when this item's preauthorization was issued.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
76. ClaimResponse.addItem.extension:preAuthPeriod
Slice NamepreAuthPeriod
Definition

The date/period when this item's preauthorization is valid.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
78. ClaimResponse.addItem.extension:previousAuthorizationNumber
Slice NamepreviousAuthorizationNumber
Definition

A string assigned by the UMO to an authorized review outcome associated with this service item.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AuthorizationNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. ClaimResponse.addItem.extension:administrationReferenceNumber
Slice NameadministrationReferenceNumber
Definition

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. ClaimResponse.addItem.extension:epsdtIndicator
Slice NameepsdtIndicator
Definition

An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(EPSDTIndicator) (Extension Type: boolean)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. ClaimResponse.addItem.extension:nursingHomeResidentialStatus
Slice NamenursingHomeResidentialStatus
Definition

A code specifying the status of a nursing home resident at the time of service. (SV209)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(NursingHomeResidentialStatus) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
86. ClaimResponse.addItem.extension:nursingHomeLevelOfCare
Slice NamenursingHomeLevelOfCare
Definition

A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(NursingHomeLevelOfCare) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
88. ClaimResponse.addItem.extension:productOrServiceCodeEnd
Slice NameproductOrServiceCodeEnd
Definition

Used to provide the last code in a series of codes for the service being requested.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ProductOrServiceCodeEnd) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
90. ClaimResponse.addItem.extension:revenue
Slice Namerevenue
Definition

A revenue code that expresses what was approved which maps to X12 SV201

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RevenueCode) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. ClaimResponse.addItem.extension:revenueUnitRateLimit
Slice NamerevenueUnitRateLimit
Definition

The limit on the rate per unit of revenue for hospital accomodation. (SV206)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RevenueUnitRateLimit) (Extension Type: decimal)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. ClaimResponse.addItem.extension:requestedService
Slice NamerequestedService
Definition

The details of the service being requested.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RequestedService) (Extension Type: Reference(PAS Medication Request, PAS Service Request, PAS Device Request, PAS Nutrition Order))
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
96. ClaimResponse.addItem.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
98. ClaimResponse.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

ShortItem sequence number
Control10..1*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Provides references to the claim items.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. ClaimResponse.addItem.provider
Definition

The providers who are authorized for the services rendered to the patient.

ShortAuthorized providers
Control0..*
TypeReference(PAS Practitioner, PAS Organization Base Profile, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. ClaimResponse.addItem.provider.extension:providerType
Slice NameproviderType
Definition

The type of provider who has been authorized to provide this item.

ShortExtension
Control0..1
TypeExtension(AuthorizedProviderType) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
104. ClaimResponse.addItem.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortBilling, service, product, or drug code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Control1..1
BindingThe codes SHALL be taken from For example codes, see X12 278 Requested Service Typehttp://hl7.org/fhir/ValueSet/service-uscls
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Necessary to state what was provided or done.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. ClaimResponse.addItem.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

ShortService/Product billing modifiers
Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Control0..*
BindingThe codes SHALL be taken from For example codes, see X12 278 Requested Service Modifier Typehttp://hl7.org/fhir/ValueSet/claim-modifiers
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. ClaimResponse.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

ShortDate or dates of service or product delivery
Control0..1
TypeChoice of: date, Period
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. ClaimResponse.addItem.location[x]
Definition

Where the product or service was provided.

ShortPlace of service or where product was supplied
Control0..1
BindingFor example codes, see ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place
(example to http://hl7.org/fhir/ValueSet/service-place)

Place of service: pharmacy, school, prison, etc.

TypeChoice of: CodeableConcept, Address, Reference(Location)
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. ClaimResponse.addItem.quantity
Definition

The comparator is not used on a SimpleQuantity


The number of repetitions of a service or product.

ShortA fixed quantity (no comparator)Count of products or services
Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

Control0..1
This element is affected by the following invariants: ele-1
TypeQuantity(PAS Quantity, SimpleQuantity)
Is Modifierfalse
Must Supporttrue
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
qty-3: If a code for the unit is present, the system SHALL also be present (code.empty() or system.exists())
sqty-1: The comparator is not used on a SimpleQuantity (comparator.empty())
114. ClaimResponse.addItem.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

ShortFee, charge or cost per item
Control0..1
TypeMoney
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The amount charged to the patient by the provider for a single unit.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ClaimResponse.addItem.adjudication
Definition

The adjudication results.

ShortAdded items adjudication
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. ClaimResponse.addItem.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
120. ClaimResponse.addItem.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
122. ClaimResponse.addItem.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. ClaimResponse.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

ShortHeader-level adjudication
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. ClaimResponse.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
128. ClaimResponse.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
130. ClaimResponse.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
132. ClaimResponse.error
Definition

Errors encountered during the processing of the adjudication.

ShortProcessing errors
Comments

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Need to communicate processing issues to the requestor.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
134. ClaimResponse.error.extension:followupAction
Slice NamefollowupAction
Definition

A code representing what action must occur to resolve this error.

ShortA code representing what action must occur to resolve this error.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorFollowupAction) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
136. ClaimResponse.error.extension:errorElement
Slice NameerrorElement
Definition

The specific loop, segment, or element that this error information is about. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103

ShortThe specific X12 loop, segment, or element that this error information is about.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorElement) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
138. ClaimResponse.error.extension:errorPath
Slice NameerrorPath
Definition

The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element.

STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element.

Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value

ShortThe FHIRPath expression that indicates which FHIR element that this error information is about.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorPath) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
140. ClaimResponse.error.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
142. ClaimResponse.error.code
Definition

An error code, from a specified code system, which details why the claim could not be adjudicated.

ShortError code detailing processing issues
Control1..1
BindingThe codes SHALL be taken from For example codes, see X12 278 Reject Reason Value Sethttp://hl7.org/fhir/ValueSet/adjudication-error
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required to convey processing errors.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

ShortResponse to a preauthorization query
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If 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-4: If 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-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. ClaimResponse.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. ClaimResponse.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ClaimResponse.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. ClaimResponse.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. ClaimResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. ClaimResponse.identifier
Definition

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

ShortAn identifier intended for computation
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
This element is affected by the following invariants: ele-1
TypeIdentifier(PAS Identifier)
Is Modifierfalse
Must Supporttrue
Requirements

Allows claim responses to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.identifier.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
22. ClaimResponse.identifier.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 24. ClaimResponse.identifier.extension:subDepartment
    Slice NamesubDepartment
    Definition

    An additional element that provides a further subdivision within the organization granting the identifier.

    ShortExtension
    Control0..1
    TypeExtension(IdentifierSubDepartment) (Extension Type: string)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    26. ClaimResponse.identifier.extension:jurisdiction
    Slice Namejurisdiction
    Definition

    An additional element that provides the assigning jurisdiction of the identifier (i.e. provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.

    ShortExtension
    Control0..1
    TypeExtension(IdentifierJurisdiction) (Extension Type: CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    28. ClaimResponse.identifier.use
    Definition

    The purpose of this identifier.

    Shortusual | official | temp | secondary | old (If known)
    Comments

    Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

    Control0..1
    BindingThe codes SHALL be taken from IdentifierUse
    (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

    Identifies the purpose for this identifier, if known .

    Typecode
    Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. ClaimResponse.identifier.type
    Definition

    A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

    ShortDescription of identifier
    Comments

    This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
    (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

    A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Allows users to make use of identifiers when the identifier system is not known.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. ClaimResponse.identifier.system
    Definition

    Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

    ShortShould use a scheme of 'urn:trnorg:<TRN03>'
    Comments

    Identifier.system is always case sensitive.

    Control1..1
    Typeuri
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

    Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. ClaimResponse.identifier.value
    Definition

    The portion of the identifier typically relevant to the user and which is unique within the context of the system.

    ShortThe value that is unique
    Comments

    If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

    Control1..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Example<br/><b>General</b>:123456
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. ClaimResponse.identifier.period
    Definition

    Time period during which identifier is/was valid for use.

    ShortTime period when id is/was valid for use
    Control0..1
    TypePeriod
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. ClaimResponse.identifier.assigner
    Definition

    Organization that issued/manages the identifier.

    ShortOrganization that issued id (may be just text)
    Comments

    The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

    Control0..1
    TypeReference(Organization)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. ClaimResponse.status
    Definition

    The status of the resource instance.

    Shortactive | cancelled | draft | entered-in-error
    Comments

    This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

    Control1..1
    BindingThe codes SHALL be taken from FinancialResourceStatusCodes
    (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

    A code specifying the state of the resource instance.

    Typecode
    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

    Pattern Valueactive
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    42. ClaimResponse.type
    Definition

    A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

    ShortMore granular claim type
    Comments

    This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
    (extensible to http://hl7.org/fhir/ValueSet/claim-type)

    The type or discipline-style of the claim.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Some jurisdictions need a finer grained claim type for routing and adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    44. ClaimResponse.subType
    Definition

    A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

    ShortMore granular claim type
    Comments

    This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

    Control0..1
    BindingFor example codes, see ExampleClaimSubTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-subtype)

    A more granular claim typecode.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Some jurisdictions need a finer grained claim type for routing and adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    46. ClaimResponse.use
    Definition

    A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

    Shortclaim | preauthorization | predetermination
    Control1..1
    BindingThe codes SHALL be taken from Use
    (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

    Claim, preauthorization, predetermination.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    This element is required to understand the nature of the request for adjudication.

    Pattern Valuepreauthorization
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    48. ClaimResponse.patient
    Definition

    The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

    ShortThe recipient of the products and services
    Control1..1
    TypeReference(PAS Beneficiary Patient)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    50. ClaimResponse.created
    Definition

    The date this resource was created.

    ShortResponse creation date
    Control1..1
    TypedateTime
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to record a timestamp for use by both the recipient and the issuer.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    52. ClaimResponse.insurer
    Definition

    The party responsible for authorization, adjudication and reimbursement.

    ShortParty responsible for reimbursement
    Control1..1
    TypeReference(PAS Insurer Organization)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    54. ClaimResponse.requestor
    Definition

    The provider which is responsible for the claim, predetermination or preauthorization.

    ShortParty responsible for the claim
    Comments

    Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

    Control0..1
    TypeReference(PAS Requestor Organization, PAS PractitionerRole)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    56. ClaimResponse.request
    Definition

    Original request resource reference.

    ShortId of resource triggering adjudication
    Control1..1
    TypeReference(PAS Claim)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    58. ClaimResponse.outcome
    Definition

    The outcome of the claim, predetermination, or preauthorization processing.

    Shortqueued | complete | error | partial
    Comments

    The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

    Control1..1
    BindingThe codes SHALL be taken from ClaimProcessingCodes
    (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

    The result of the claim processing.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    To advise the requestor of an overall processing outcome.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    60. ClaimResponse.disposition
    Definition

    A human readable description of the status of the adjudication.

    ShortDisposition Message
    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    Provided for user display.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    62. ClaimResponse.preAuthRef
    Definition

    Reference from the Insurer which is used in later communications which refers to this adjudication.

    ShortPreauthorization reference
    Comments

    This value is only present on preauthorization adjudications.

    Control0..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summaryfalse
    Requirements

    On subsequent claims, the insurer may require the provider to quote this value.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    64. ClaimResponse.preAuthPeriod
    Definition

    The time frame during which this authorization is effective.

    ShortPreauthorization reference effective period
    Control0..1
    TypePeriod
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    66. ClaimResponse.payeeType
    Definition

    Type of Party to be reimbursed: subscriber, provider, other.

    ShortParty to be paid any benefits payable
    Control0..1
    BindingFor example codes, see Claim Payee Type Codes
    (example to http://hl7.org/fhir/ValueSet/payeetype)

    A code for the party to be reimbursed.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    68. ClaimResponse.item
    Definition

    A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

    ShortAdjudication for claim line items
    Control0..*
    TypeBackboneElement
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Requirements

    The adjudication for items provided on the claim.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    70. ClaimResponse.item.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    72. ClaimResponse.item.extension
    Definition

    An Extension

    ShortExtension
    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on ClaimResponse.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 74. ClaimResponse.item.extension:itemTraceNumber
      Slice NameitemTraceNumber
      Definition

      Uniquely identifies this claim item. (2000F-TRN)

      ShortUniquely identifies this claim item. (2000F-TRN)
      Control0..*
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      76. ClaimResponse.item.extension:preAuthIssueDate
      Slice NamepreAuthIssueDate
      Definition

      The date when this item's preauthorization was issued.

      ShortThe date when this item's preauthorization was issued.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      78. ClaimResponse.item.extension:preAuthPeriod
      Slice NamepreAuthPeriod
      Definition

      The date/period when this item's preauthorization is valid.

      ShortThe date/period when this item's preauthorization is valid.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      80. ClaimResponse.item.extension:previousAuthorizationNumber
      Slice NamepreviousAuthorizationNumber
      Definition

      A string assigned by the UMO to an authorized review outcome associated with this service item.

      ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(AuthorizationNumber) (Extension Type: string)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      82. ClaimResponse.item.extension:administrationReferenceNumber
      Slice NameadministrationReferenceNumber
      Definition

      A string assigned by the UMO to the original disallowed review outcome associated with this service item.

      ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      84. ClaimResponse.item.extension:requestedServiceDate
      Slice NamerequestedServiceDate
      Definition

      The original date/period that was requested by the submitter for this item.

      ShortThe original date/period that was requested by the submitter for this item.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemRequestedServiceDate) (Extension Type: Choice of: dateTime, Period)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      86. ClaimResponse.item.extension:authorizedProvider
      Slice NameauthorizedProvider
      Definition

      The specific provider who has been authorized to provide this item.

      ShortThe specific provider who has been authorized to provide this item.
      Control0..*
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemAuthorizedProvider) (Complex Extension)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      88. ClaimResponse.item.extension:authorizedItemDetail
      Slice NameauthorizedItemDetail
      Definition

      The details of what has been authorized for this item.

      ShortThe details of what has been authorized for this item.
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(ItemAuthorizedDetail) (Complex Extension)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      90. ClaimResponse.item.extension:communicatedDiagnosis
      Slice NamecommunicatedDiagnosis
      Definition

      A code representing the diagnosis that is the subject of the communication

      ShortA code representing the diagnosis that is relevant to the preauthorization.
      Control0..1
      TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      92. ClaimResponse.item.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored even if unrecognized
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
      Summarytrue
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content, modifiers
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      94. ClaimResponse.item.itemSequence
      Definition

      A number to uniquely reference the claim item entries.

      ShortClaim item instance identifier
      Control1..1
      TypepositiveInt
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summaryfalse
      Requirements

      Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      96. ClaimResponse.item.noteNumber
      Definition

      The numbers associated with notes below which apply to the adjudication of this item.

      ShortApplicable note numbers
      Control0..*
      TypepositiveInt
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Requirements

      Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      98. ClaimResponse.item.adjudication
      Definition

      If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

      ShortAdjudication details
      Control1..*
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      100. ClaimResponse.item.adjudication.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      102. ClaimResponse.item.adjudication.extension
      Definition

      An Extension

      ShortExtension
      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on ClaimResponse.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 104. ClaimResponse.item.adjudication.extension:reviewAction
        Slice NamereviewAction
        Definition

        The details of the review action that is necessary for the authorization.

        ShortThe details of the review action that is necessary for the authorization.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(ReviewAction) (Complex Extension)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        106. ClaimResponse.item.adjudication.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        108. ClaimResponse.item.adjudication.category
        Definition

        A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

        ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
        Comments

        For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

        Control1..1
        BindingFor example codes, see AdjudicationValueCodes
        (example to http://hl7.org/fhir/ValueSet/adjudication)

        The adjudication codes.

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Requirements

        Needed to enable understanding of the context of the other information in the adjudication.

        Pattern Value{
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
            "code" : "submitted"
          }]
        }
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        110. ClaimResponse.item.adjudication.reason
        Definition

        A code supporting the understanding of the adjudication result and explaining variance from expected amount.

        ShortExplanation of adjudication outcome
        Comments

        For example may indicate that the funds for this benefit type have been exhausted.

        Control0..1
        BindingFor example codes, see AdjudicationReasonCodes
        (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

        The adjudication reason codes.

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Requirements

        To support understanding of variance from adjudication expectations.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        112. ClaimResponse.item.adjudication.amount
        Definition

        Monetary amount associated with the category.

        ShortMonetary amount
        Comments

        For example: amount submitted, eligible amount, co-payment, and benefit payable.

        Control0..1
        TypeMoney
        Is Modifierfalse
        Summaryfalse
        Requirements

        Most adjuciation categories convey a monetary amount.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        114. ClaimResponse.item.adjudication.value
        Definition

        A non-monetary value associated with the category. Mutually exclusive to the amount element above.

        ShortNon-monetary value
        Comments

        For example: eligible percentage or co-payment percentage.

        Control0..1
        Typedecimal
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        Some adjudication categories convey a percentage or a fixed value.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        116. ClaimResponse.item.detail
        Definition

        A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

        ShortAdjudication for claim details
        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summaryfalse
        Requirements

        The adjudication for details provided on the claim.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        118. ClaimResponse.item.detail.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        120. ClaimResponse.item.detail.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        122. ClaimResponse.item.detail.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        124. ClaimResponse.item.detail.detailSequence
        Definition

        A number to uniquely reference the claim detail entry.

        ShortClaim detail instance identifier
        Control1..1
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        126. ClaimResponse.item.detail.noteNumber
        Definition

        The numbers associated with notes below which apply to the adjudication of this item.

        ShortApplicable note numbers
        Control0..*
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        128. ClaimResponse.item.detail.adjudication
        Definition

        The adjudication results.

        ShortDetail level adjudication details
        Control1..*
        TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        130. ClaimResponse.item.detail.subDetail
        Definition

        A sub-detail adjudication of a simple product or service.

        ShortAdjudication for claim sub-details
        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Summaryfalse
        Requirements

        The adjudication for sub-details provided on the claim.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        132. ClaimResponse.item.detail.subDetail.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        134. ClaimResponse.item.detail.subDetail.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        136. ClaimResponse.item.detail.subDetail.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        138. ClaimResponse.item.detail.subDetail.subDetailSequence
        Definition

        A number to uniquely reference the claim sub-detail entry.

        ShortClaim sub-detail instance identifier
        Control1..1
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        140. ClaimResponse.item.detail.subDetail.noteNumber
        Definition

        The numbers associated with notes below which apply to the adjudication of this item.

        ShortApplicable note numbers
        Control0..*
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Requirements

        Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        142. ClaimResponse.item.detail.subDetail.adjudication
        Definition

        The adjudication results.

        ShortSubdetail level adjudication details
        Control0..*
        TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        144. ClaimResponse.addItem
        Definition

        The first-tier service adjudications for payor added product or service lines.

        ShortInsurer added line items
        Control0..*
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        146. ClaimResponse.addItem.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        148. ClaimResponse.addItem.extension
        Definition

        An Extension

        ShortExtension
        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on ClaimResponse.addItem.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 150. ClaimResponse.addItem.extension:itemTraceNumber
          Slice NameitemTraceNumber
          Definition

          Uniquely identifies this claim item. (2000F-TRN)

          ShortExtension
          Control0..*
          This element is affected by the following invariants: ele-1
          TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          152. ClaimResponse.addItem.extension:preAuthIssueDate
          Slice NamepreAuthIssueDate
          Definition

          The date when this item's preauthorization was issued.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          154. ClaimResponse.addItem.extension:preAuthPeriod
          Slice NamepreAuthPeriod
          Definition

          The date/period when this item's preauthorization is valid.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          156. ClaimResponse.addItem.extension:previousAuthorizationNumber
          Slice NamepreviousAuthorizationNumber
          Definition

          A string assigned by the UMO to an authorized review outcome associated with this service item.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(AuthorizationNumber) (Extension Type: string)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          158. ClaimResponse.addItem.extension:administrationReferenceNumber
          Slice NameadministrationReferenceNumber
          Definition

          A string assigned by the UMO to the original disallowed review outcome associated with this service item.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          160. ClaimResponse.addItem.extension:epsdtIndicator
          Slice NameepsdtIndicator
          Definition

          An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(EPSDTIndicator) (Extension Type: boolean)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          162. ClaimResponse.addItem.extension:nursingHomeResidentialStatus
          Slice NamenursingHomeResidentialStatus
          Definition

          A code specifying the status of a nursing home resident at the time of service. (SV209)

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(NursingHomeResidentialStatus) (Extension Type: CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          164. ClaimResponse.addItem.extension:nursingHomeLevelOfCare
          Slice NamenursingHomeLevelOfCare
          Definition

          A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(NursingHomeLevelOfCare) (Extension Type: CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          166. ClaimResponse.addItem.extension:productOrServiceCodeEnd
          Slice NameproductOrServiceCodeEnd
          Definition

          Used to provide the last code in a series of codes for the service being requested.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(ProductOrServiceCodeEnd) (Extension Type: CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          168. ClaimResponse.addItem.extension:revenue
          Slice Namerevenue
          Definition

          A revenue code that expresses what was approved which maps to X12 SV201

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(RevenueCode) (Extension Type: CodeableConcept)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          170. ClaimResponse.addItem.extension:revenueUnitRateLimit
          Slice NamerevenueUnitRateLimit
          Definition

          The limit on the rate per unit of revenue for hospital accomodation. (SV206)

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(RevenueUnitRateLimit) (Extension Type: decimal)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          172. ClaimResponse.addItem.extension:requestedService
          Slice NamerequestedService
          Definition

          The details of the service being requested.

          ShortExtension
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(RequestedService) (Extension Type: Reference(PAS Medication Request, PAS Service Request, PAS Device Request, PAS Nutrition Order))
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          174. ClaimResponse.addItem.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          176. ClaimResponse.addItem.itemSequence
          Definition

          Claim items which this service line is intended to replace.

          ShortItem sequence number
          Control1..1
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summaryfalse
          Requirements

          Provides references to the claim items.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          178. ClaimResponse.addItem.detailSequence
          Definition

          The sequence number of the details within the claim item which this line is intended to replace.

          ShortDetail sequence number
          Control0..*
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Provides references to the claim details within the claim item.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          180. ClaimResponse.addItem.subdetailSequence
          Definition

          The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

          ShortSubdetail sequence number
          Control0..*
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Provides references to the claim sub-details within the claim detail.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          182. ClaimResponse.addItem.provider
          Definition

          The providers who are authorized for the services rendered to the patient.

          ShortAuthorized providers
          Control0..*
          TypeReference(PAS Practitioner, PAS Organization Base Profile)
          Is Modifierfalse
          Must Supporttrue
          Must Support TypesNo must-support rules about the choice of types/profiles
          Summaryfalse
          Requirements

          Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          184. ClaimResponse.addItem.provider.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          186. ClaimResponse.addItem.provider.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on ClaimResponse.addItem.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 188. ClaimResponse.addItem.provider.extension:providerType
            Slice NameproviderType
            Definition

            The type of provider who has been authorized to provide this item.

            ShortExtension
            Control0..1
            TypeExtension(AuthorizedProviderType) (Extension Type: CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            190. ClaimResponse.addItem.provider.reference
            Definition

            A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

            ShortLiteral reference, Relative, internal or absolute URL
            Comments

            Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

            Control0..1
            This element is affected by the following invariants: ref-1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            192. ClaimResponse.addItem.provider.type
            Definition

            The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

            The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

            ShortType the reference refers to (e.g. "Patient")
            Comments

            This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

            Control0..1
            BindingUnless not suitable, these codes SHALL be taken from ResourceType
            (extensible to http://hl7.org/fhir/ValueSet/resource-types)

            Aa resource (or, for logical models, the URI of the logical model).

            Typeuri
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            194. ClaimResponse.addItem.provider.identifier
            Definition

            An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

            ShortLogical reference, when literal reference is not known
            Comments

            When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

            When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

            Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

            Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

            NoteThis is a business identifier, not a resource identifier (see discussion)
            Control0..1
            TypeIdentifier
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            196. ClaimResponse.addItem.provider.display
            Definition

            Plain text narrative that identifies the resource in addition to the resource reference.

            ShortText alternative for the resource
            Comments

            This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            198. ClaimResponse.addItem.productOrService
            Definition

            When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

            ShortBilling, service, product, or drug code
            Comments

            If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

            Control1..1
            BindingThe codes SHALL be taken from X12 278 Requested Service Type
            (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType)
            TypeCodeableConcept
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Requirements

            Necessary to state what was provided or done.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            200. ClaimResponse.addItem.modifier
            Definition

            Item typification or modifiers codes to convey additional context for the product or service.

            ShortService/Product billing modifiers
            Comments

            For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

            Control0..*
            BindingThe codes SHALL be taken from X12 278 Requested Service Modifier Type
            (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType)
            TypeCodeableConcept
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Requirements

            To support inclusion of the item for adjudication or to charge an elevated fee.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            202. ClaimResponse.addItem.programCode
            Definition

            Identifies the program under which this may be recovered.

            ShortProgram the product or service is provided under
            Comments

            For example: Neonatal program, child dental program or drug users recovery program.

            Control0..*
            BindingFor example codes, see ExampleProgramReasonCodes
            (example to http://hl7.org/fhir/ValueSet/ex-program-code)

            Program specific reason codes.

            TypeCodeableConcept
            Is Modifierfalse
            Summaryfalse
            Requirements

            Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            204. ClaimResponse.addItem.serviced[x]
            Definition

            The date or dates when the service or product was supplied, performed or completed.

            ShortDate or dates of service or product delivery
            Control0..1
            TypeChoice of: date, Period
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Must Support TypesNo must-support rules about the choice of types/profiles
            Summaryfalse
            Requirements

            Needed to determine whether the service or product was provided during the term of the insurance coverage.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            206. ClaimResponse.addItem.location[x]
            Definition

            Where the product or service was provided.

            ShortPlace of service or where product was supplied
            Control0..1
            BindingFor example codes, see ExampleServicePlaceCodes
            (example to http://hl7.org/fhir/ValueSet/service-place)

            Place of service: pharmacy, school, prison, etc.

            TypeChoice of: CodeableConcept, Address, Reference(Location)
            [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
            Is Modifierfalse
            Must Supporttrue
            Must Support TypesNo must-support rules about the choice of types/profiles
            Summaryfalse
            Requirements

            The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            208. ClaimResponse.addItem.quantity
            Definition

            The comparator is not used on a SimpleQuantity

            ShortA fixed quantity (no comparator)
            Comments

            The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

            Control0..1
            This element is affected by the following invariants: ele-1
            TypeQuantity(PAS Quantity)
            Is Modifierfalse
            Must Supporttrue
            Requirements

            Required when the product or service code does not convey the quantity provided.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            qty-3: If a code for the unit is present, the system SHALL also be present (code.empty() or system.exists())
            sqty-1: The comparator is not used on a SimpleQuantity (comparator.empty())
            210. ClaimResponse.addItem.unitPrice
            Definition

            If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

            ShortFee, charge or cost per item
            Control0..1
            TypeMoney
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Requirements

            The amount charged to the patient by the provider for a single unit.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            212. ClaimResponse.addItem.factor
            Definition

            A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

            ShortPrice scaling factor
            Comments

            To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

            Control0..1
            Typedecimal
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summaryfalse
            Requirements

            When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            214. ClaimResponse.addItem.net
            Definition

            The quantity times the unit price for an additional service or product or charge.

            ShortTotal item cost
            Comments

            For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

            Control0..1
            TypeMoney
            Is Modifierfalse
            Summaryfalse
            Requirements

            Provides the total amount claimed for the group (if a grouper) or the line item.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            216. ClaimResponse.addItem.bodySite
            Definition

            Physical service site on the patient (limb, tooth, etc.).

            ShortAnatomical location
            Comments

            For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

            Control0..1
            BindingFor example codes, see OralSiteCodes
            (example to http://hl7.org/fhir/ValueSet/tooth)

            The code for the teeth, quadrant, sextant and arch.

            TypeCodeableConcept
            Is Modifierfalse
            Summaryfalse
            Requirements

            Allows insurer to validate specific procedures.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            218. ClaimResponse.addItem.subSite
            Definition

            A region or surface of the bodySite, e.g. limb region or tooth surface(s).

            ShortAnatomical sub-location
            Control0..*
            BindingFor example codes, see SurfaceCodes
            (example to http://hl7.org/fhir/ValueSet/surface)

            The code for the tooth surface and surface combinations.

            TypeCodeableConcept
            Is Modifierfalse
            Summaryfalse
            Requirements

            Allows insurer to validate specific procedures.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            220. ClaimResponse.addItem.noteNumber
            Definition

            The numbers associated with notes below which apply to the adjudication of this item.

            ShortApplicable note numbers
            Control0..*
            TypepositiveInt
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summaryfalse
            Requirements

            Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            222. ClaimResponse.addItem.adjudication
            Definition

            The adjudication results.

            ShortAdded items adjudication
            Control1..*
            TypeBackboneElement
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            224. ClaimResponse.addItem.adjudication.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            226. ClaimResponse.addItem.adjudication.extension
            Definition

            An Extension

            ShortExtension
            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on ClaimResponse.addItem.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 228. ClaimResponse.addItem.adjudication.extension:reviewAction
              Slice NamereviewAction
              Definition

              The details of the review action that is necessary for the authorization.

              ShortThe details of the review action that is necessary for the authorization.
              Control0..1
              This element is affected by the following invariants: ele-1
              TypeExtension(ReviewAction) (Complex Extension)
              Is Modifierfalse
              Must Supporttrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              230. ClaimResponse.addItem.adjudication.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              ShortExtensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summarytrue
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Namesextensions, user content, modifiers
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              232. ClaimResponse.addItem.adjudication.category
              Definition

              A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

              ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
              Comments

              For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

              Control1..1
              BindingFor example codes, see AdjudicationValueCodes
              (example to http://hl7.org/fhir/ValueSet/adjudication)

              The adjudication codes.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Needed to enable understanding of the context of the other information in the adjudication.

              Pattern Value{
                "coding" : [{
                  "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                  "code" : "submitted"
                }]
              }
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              234. ClaimResponse.addItem.adjudication.reason
              Definition

              A code supporting the understanding of the adjudication result and explaining variance from expected amount.

              ShortExplanation of adjudication outcome
              Comments

              For example may indicate that the funds for this benefit type have been exhausted.

              Control0..1
              BindingFor example codes, see AdjudicationReasonCodes
              (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

              The adjudication reason codes.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              To support understanding of variance from adjudication expectations.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              236. ClaimResponse.addItem.adjudication.amount
              Definition

              Monetary amount associated with the category.

              ShortMonetary amount
              Comments

              For example: amount submitted, eligible amount, co-payment, and benefit payable.

              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              Most adjuciation categories convey a monetary amount.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              238. ClaimResponse.addItem.adjudication.value
              Definition

              A non-monetary value associated with the category. Mutually exclusive to the amount element above.

              ShortNon-monetary value
              Comments

              For example: eligible percentage or co-payment percentage.

              Control0..1
              Typedecimal
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              Some adjudication categories convey a percentage or a fixed value.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              240. ClaimResponse.addItem.detail
              Definition

              The second-tier service adjudications for payor added services.

              ShortInsurer added line details
              Control0..*
              TypeBackboneElement
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              242. ClaimResponse.addItem.detail.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              244. ClaimResponse.addItem.detail.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              ShortAdditional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Alternate Namesextensions, user content
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              246. ClaimResponse.addItem.detail.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              ShortExtensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summarytrue
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Namesextensions, user content, modifiers
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              248. ClaimResponse.addItem.detail.productOrService
              Definition

              When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

              ShortBilling, service, product, or drug code
              Comments

              If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

              Control1..1
              BindingFor example codes, see USCLSCodes
              (example to http://hl7.org/fhir/ValueSet/service-uscls)

              Allowable service and product codes.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Necessary to state what was provided or done.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              250. ClaimResponse.addItem.detail.modifier
              Definition

              Item typification or modifiers codes to convey additional context for the product or service.

              ShortService/Product billing modifiers
              Comments

              For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

              Control0..*
              BindingFor example codes, see ModifierTypeCodes
              (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

              Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              To support inclusion of the item for adjudication or to charge an elevated fee.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              252. ClaimResponse.addItem.detail.quantity
              Definition

              The number of repetitions of a service or product.

              ShortCount of products or services
              Control0..1
              TypeQuantity(SimpleQuantity)
              Is Modifierfalse
              Summaryfalse
              Requirements

              Required when the product or service code does not convey the quantity provided.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              254. ClaimResponse.addItem.detail.unitPrice
              Definition

              If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

              ShortFee, charge or cost per item
              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              The amount charged to the patient by the provider for a single unit.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              256. ClaimResponse.addItem.detail.factor
              Definition

              A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

              ShortPrice scaling factor
              Comments

              To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

              Control0..1
              Typedecimal
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              258. ClaimResponse.addItem.detail.net
              Definition

              The quantity times the unit price for an additional service or product or charge.

              ShortTotal item cost
              Comments

              For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              Provides the total amount claimed for the group (if a grouper) or the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              260. ClaimResponse.addItem.detail.noteNumber
              Definition

              The numbers associated with notes below which apply to the adjudication of this item.

              ShortApplicable note numbers
              Control0..*
              TypepositiveInt
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              262. ClaimResponse.addItem.detail.adjudication
              Definition

              The adjudication results.

              ShortAdded items detail adjudication
              Control1..*
              TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              264. ClaimResponse.addItem.detail.subDetail
              Definition

              The third-tier service adjudications for payor added services.

              ShortInsurer added line items
              Control0..*
              TypeBackboneElement
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              266. ClaimResponse.addItem.detail.subDetail.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              268. ClaimResponse.addItem.detail.subDetail.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              ShortAdditional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Alternate Namesextensions, user content
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              270. ClaimResponse.addItem.detail.subDetail.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              ShortExtensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summarytrue
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Namesextensions, user content, modifiers
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              272. ClaimResponse.addItem.detail.subDetail.productOrService
              Definition

              When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

              ShortBilling, service, product, or drug code
              Comments

              If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

              Control1..1
              BindingFor example codes, see USCLSCodes
              (example to http://hl7.org/fhir/ValueSet/service-uscls)

              Allowable service and product codes.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Necessary to state what was provided or done.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              274. ClaimResponse.addItem.detail.subDetail.modifier
              Definition

              Item typification or modifiers codes to convey additional context for the product or service.

              ShortService/Product billing modifiers
              Comments

              For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

              Control0..*
              BindingFor example codes, see ModifierTypeCodes
              (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

              Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              To support inclusion of the item for adjudication or to charge an elevated fee.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              276. ClaimResponse.addItem.detail.subDetail.quantity
              Definition

              The number of repetitions of a service or product.

              ShortCount of products or services
              Control0..1
              TypeQuantity(SimpleQuantity)
              Is Modifierfalse
              Summaryfalse
              Requirements

              Required when the product or service code does not convey the quantity provided.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              278. ClaimResponse.addItem.detail.subDetail.unitPrice
              Definition

              If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

              ShortFee, charge or cost per item
              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              The amount charged to the patient by the provider for a single unit.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              280. ClaimResponse.addItem.detail.subDetail.factor
              Definition

              A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

              ShortPrice scaling factor
              Comments

              To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

              Control0..1
              Typedecimal
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              282. ClaimResponse.addItem.detail.subDetail.net
              Definition

              The quantity times the unit price for an additional service or product or charge.

              ShortTotal item cost
              Comments

              For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              Provides the total amount claimed for the group (if a grouper) or the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              284. ClaimResponse.addItem.detail.subDetail.noteNumber
              Definition

              The numbers associated with notes below which apply to the adjudication of this item.

              ShortApplicable note numbers
              Control0..*
              TypepositiveInt
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              286. ClaimResponse.addItem.detail.subDetail.adjudication
              Definition

              The adjudication results.

              ShortAdded items detail adjudication
              Control1..*
              TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              288. ClaimResponse.adjudication
              Definition

              The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

              ShortHeader-level adjudication
              Control0..*
              TypeBackboneElement
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              290. ClaimResponse.adjudication.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              292. ClaimResponse.adjudication.extension
              Definition

              An Extension

              ShortExtension
              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              SlicingThis element introduces a set of slices on ClaimResponse.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 294. ClaimResponse.adjudication.extension:reviewAction
                Slice NamereviewAction
                Definition

                The details of the review action that is necessary for the authorization.

                ShortThe details of the review action that is necessary for the authorization.
                Control0..1
                This element is affected by the following invariants: ele-1
                TypeExtension(ReviewAction) (Complex Extension)
                Is Modifierfalse
                Must Supporttrue
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                296. ClaimResponse.adjudication.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                298. ClaimResponse.adjudication.category
                Definition

                A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

                ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
                Comments

                For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                Control1..1
                BindingFor example codes, see AdjudicationValueCodes
                (example to http://hl7.org/fhir/ValueSet/adjudication)

                The adjudication codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to enable understanding of the context of the other information in the adjudication.

                Pattern Value{
                  "coding" : [{
                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code" : "submitted"
                  }]
                }
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                300. ClaimResponse.adjudication.reason
                Definition

                A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                ShortExplanation of adjudication outcome
                Comments

                For example may indicate that the funds for this benefit type have been exhausted.

                Control0..1
                BindingFor example codes, see AdjudicationReasonCodes
                (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                The adjudication reason codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                To support understanding of variance from adjudication expectations.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                302. ClaimResponse.adjudication.amount
                Definition

                Monetary amount associated with the category.

                ShortMonetary amount
                Comments

                For example: amount submitted, eligible amount, co-payment, and benefit payable.

                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                Most adjuciation categories convey a monetary amount.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                304. ClaimResponse.adjudication.value
                Definition

                A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                ShortNon-monetary value
                Comments

                For example: eligible percentage or co-payment percentage.

                Control0..1
                Typedecimal
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Some adjudication categories convey a percentage or a fixed value.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                306. ClaimResponse.total
                Definition

                Categorized monetary totals for the adjudication.

                ShortAdjudication totals
                Comments

                Totals for amounts submitted, co-pays, benefits payable etc.

                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summarytrue
                Requirements

                To provide the requestor with financial totals by category for the adjudication.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                308. ClaimResponse.total.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                310. ClaimResponse.total.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                312. ClaimResponse.total.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                314. ClaimResponse.total.category
                Definition

                A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                ShortType of adjudication information
                Comments

                For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                Control1..1
                BindingFor example codes, see AdjudicationValueCodes
                (example to http://hl7.org/fhir/ValueSet/adjudication)

                The adjudication codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summarytrue
                Requirements

                Needed to convey the type of total provided.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                316. ClaimResponse.total.amount
                Definition

                Monetary total amount associated with the category.

                ShortFinancial total for the category
                Control1..1
                TypeMoney
                Is Modifierfalse
                Summarytrue
                Requirements

                Needed to convey the total monetary amount.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                318. ClaimResponse.payment
                Definition

                Payment details for the adjudication of the claim.

                ShortPayment Details
                Control0..1
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to convey references to the financial instrument that has been used if payment has been made.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                320. ClaimResponse.payment.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                322. ClaimResponse.payment.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                324. ClaimResponse.payment.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                326. ClaimResponse.payment.type
                Definition

                Whether this represents partial or complete payment of the benefits payable.

                ShortPartial or complete payment
                Control1..1
                BindingFor example codes, see ExamplePaymentTypeCodes
                (example to http://hl7.org/fhir/ValueSet/ex-paymenttype)

                The type (partial, complete) of the payment.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                To advise the requestor when the insurer believes all payments to have been completed.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                328. ClaimResponse.payment.adjustment
                Definition

                Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

                ShortPayment adjustment for non-claim issues
                Comments

                Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                To advise the requestor of adjustments applied to the payment.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                330. ClaimResponse.payment.adjustmentReason
                Definition

                Reason for the payment adjustment.

                ShortExplanation for the adjustment
                Control0..1
                BindingFor example codes, see PaymentAdjustmentReasonCodes
                (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason)

                Payment Adjustment reason codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to clarify the monetary adjustment.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                332. ClaimResponse.payment.date
                Definition

                Estimated date the payment will be issued or the actual issue date of payment.

                ShortExpected date of payment
                Control0..1
                Typedate
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                To advise the payee when payment can be expected.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                334. ClaimResponse.payment.amount
                Definition

                Benefits payable less any payment adjustment.

                ShortPayable amount after adjustment
                Control1..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to provide the actual payment amount.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                336. ClaimResponse.payment.identifier
                Definition

                Issuer's unique identifier for the payment instrument.

                ShortBusiness identifier for the payment
                Comments

                For example: EFT number or check number.

                NoteThis is a business identifier, not a resource identifier (see discussion)
                Control0..1
                TypeIdentifier
                Is Modifierfalse
                Summaryfalse
                Requirements

                Enable the receiver to reconcile when payment received.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                338. ClaimResponse.fundsReserve
                Definition

                A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

                ShortFunds reserved status
                Comments

                Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

                Control0..1
                BindingFor example codes, see Funds Reservation Codes
                (example to http://hl7.org/fhir/ValueSet/fundsreserve)

                For whom funds are to be reserved: (Patient, Provider, None).

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                340. ClaimResponse.formCode
                Definition

                A code for the form to be used for printing the content.

                ShortPrinted form identifier
                Comments

                May be needed to identify specific jurisdictional forms.

                Control0..1
                BindingFor example codes, see Form Codes
                (example to http://hl7.org/fhir/ValueSet/forms)

                The forms codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to specify the specific form used for producing output for this response.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                342. ClaimResponse.form
                Definition

                The actual form, by reference or inclusion, for printing the content or an EOB.

                ShortPrinted reference or actual form
                Comments

                Needed to permit insurers to include the actual form.

                Control0..1
                TypeAttachment
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to include the specific form used for producing output for this response.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                344. ClaimResponse.processNote
                Definition

                A note that describes or explains adjudication results in a human readable form.

                ShortNote concerning adjudication
                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Requirements

                Provides the insurer specific textual explanations associated with the processing.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                346. ClaimResponse.processNote.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                348. ClaimResponse.processNote.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                350. ClaimResponse.processNote.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                352. ClaimResponse.processNote.number
                Definition

                A number to uniquely identify a note entry.

                ShortNote instance identifier
                Control0..1
                TypepositiveInt
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Necessary to provide a mechanism to link from adjudications.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                354. ClaimResponse.processNote.type
                Definition

                The business purpose of the note text.

                Shortdisplay | print | printoper
                Control0..1
                BindingThe codes SHALL be taken from NoteType
                (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)

                The presentation types of notes.

                Typecode
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                To convey the expectation for when the text is used.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                356. ClaimResponse.processNote.text
                Definition

                The explanation or description associated with the processing.

                ShortNote explanatory text
                Control1..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Required to provide human readable explanation.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                358. ClaimResponse.processNote.language
                Definition

                A code to define the language used in the text of the note.

                ShortLanguage of the text
                Comments

                Only required if the language is different from the resource language.

                Control0..1
                BindingThe codes SHOULD be taken from CommonLanguages
                (preferred to http://hl7.org/fhir/ValueSet/languages)

                A human language.

                Additional BindingsPurpose
                AllLanguagesMax Binding
                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Note text may vary from the resource defined language.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                360. ClaimResponse.communicationRequest
                Definition

                Request for additional supporting or authorizing information.

                ShortRequest for additional information
                Comments

                For example: professional reports, documents, images, clinical resources, or accident reports.

                Control0..*
                TypeReference(CommunicationRequest)
                Is Modifierfalse
                Summaryfalse
                Requirements

                Need to communicate insurer request for additional information required to support the adjudication.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                362. ClaimResponse.insurance
                Definition

                Financial instruments for reimbursement for the health care products and services specified on the claim.

                ShortPatient insurance information
                Comments

                All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Requirements

                At least one insurer is required for a claim to be a claim.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                364. ClaimResponse.insurance.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                366. ClaimResponse.insurance.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                368. ClaimResponse.insurance.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                370. ClaimResponse.insurance.sequence
                Definition

                A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

                ShortInsurance instance identifier
                Control1..1
                TypepositiveInt
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                To maintain order of the coverages.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                372. ClaimResponse.insurance.focal
                Definition

                A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

                ShortCoverage to be used for adjudication
                Comments

                A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

                Control1..1
                Typeboolean
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                To identify which coverage in the list is being used to adjudicate this claim.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                374. ClaimResponse.insurance.coverage
                Definition

                Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

                ShortInsurance information
                Control1..1
                TypeReference(Coverage)
                Is Modifierfalse
                Summaryfalse
                Requirements

                Required to allow the adjudicator to locate the correct policy and history within their information system.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                376. ClaimResponse.insurance.businessArrangement
                Definition

                A business agreement number established between the provider and the insurer for special business processing purposes.

                ShortAdditional provider contract number
                Control0..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                378. ClaimResponse.insurance.claimResponse
                Definition

                The result of the adjudication of the line items for the Coverage specified in this insurance.

                ShortAdjudication results
                Comments

                Must not be specified when 'focal=true' for this insurance.

                Control0..1
                TypeReference(ClaimResponse)
                Is Modifierfalse
                Summaryfalse
                Requirements

                An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                380. ClaimResponse.error
                Definition

                Errors encountered during the processing of the adjudication.

                ShortProcessing errors
                Comments

                If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Must Supporttrue
                Summaryfalse
                Requirements

                Need to communicate processing issues to the requestor.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                382. ClaimResponse.error.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                384. ClaimResponse.error.extension
                Definition

                An Extension

                ShortExtension
                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                SlicingThis element introduces a set of slices on ClaimResponse.error.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 386. ClaimResponse.error.extension:followupAction
                  Slice NamefollowupAction
                  Definition

                  A code representing what action must occur to resolve this error.

                  ShortA code representing what action must occur to resolve this error.
                  Control0..1
                  This element is affected by the following invariants: ele-1
                  TypeExtension(ErrorFollowupAction) (Extension Type: CodeableConcept)
                  Is Modifierfalse
                  Must Supporttrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  388. ClaimResponse.error.extension:errorElement
                  Slice NameerrorElement
                  Definition

                  The specific loop, segment, or element that this error information is about. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103

                  ShortThe specific X12 loop, segment, or element that this error information is about.
                  Control0..1
                  This element is affected by the following invariants: ele-1
                  TypeExtension(ErrorElement) (Extension Type: string)
                  Is Modifierfalse
                  Must Supporttrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  390. ClaimResponse.error.extension:errorPath
                  Slice NameerrorPath
                  Definition

                  The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element.

                  STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element.

                  Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value

                  ShortThe FHIRPath expression that indicates which FHIR element that this error information is about.
                  Control0..1
                  This element is affected by the following invariants: ele-1
                  TypeExtension(ErrorPath) (Extension Type: string)
                  Is Modifierfalse
                  Must Supporttrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  392. ClaimResponse.error.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  394. ClaimResponse.error.itemSequence
                  Definition

                  The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                  ShortItem sequence number
                  Control0..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  Provides references to the claim items.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  396. ClaimResponse.error.detailSequence
                  Definition

                  The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                  ShortDetail sequence number
                  Control0..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  Provides references to the claim details within the claim item.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  398. ClaimResponse.error.subDetailSequence
                  Definition

                  The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                  ShortSubdetail sequence number
                  Control0..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  Provides references to the claim sub-details within the claim detail.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  400. ClaimResponse.error.code
                  Definition

                  An error code, from a specified code system, which details why the claim could not be adjudicated.

                  ShortError code detailing processing issues
                  Control1..1
                  BindingThe codes SHALL be taken from X12 278 Reject Reason Value Set
                  (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes)
                  TypeCodeableConcept
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Required to convey processing errors.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))