Profile Comparison between http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse vs http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse

Messages

Metadata

Name	Value		Comments
abstract	false
baseDefinition	http://hl7.org/fhir/StructureDefinition/ClaimResponse
copyright	Used by permission of HL7 International, all rights reserved Creative Commons License
date	2022-04-20
description	The QI Core ClaimResponse profile is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the ClaimResponse resource when using this profile
experimental	false
fhirVersion	4.0.1
jurisdiction
jurisdiction[0]	urn:iso:std:iso:3166#US
kind	resource
name	QICoreClaimResponse
publisher	http://www.hl7.org/Special/committees/cqi/index.cfm
purpose
status	draft
title	QICore Claim Response
type	ClaimResponse
url	http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse
version	5.0.0-ballot

Structure

Name	L Flags	L Card.	L Type	L Description & Constraints	R Flags	R Card.	L Type	L Description & Constraints	Comments
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	string	Logical id of this artifact	Σ	0..1	string	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: todo (preferred): A human language. Additional Bindings Purpose todo Max Binding		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for a claim response		0..*	Identifier	Business Identifier for a claim response
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: todo (required): A code specifying the state of the resource instance. Fixed Value: active	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	More granular claim type Binding: todo (extensible): The type or discipline-style of the claim.	SΣ	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: todo (example): A more granular claim typecode.		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: todo (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)	The recipient of the products and services	SΣ	1..1	Reference(QICorePatient)	The recipient of the products and services	Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient]])
created	SΣ	1..1	dateTime	Response creation date	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)	Party responsible for reimbursement	SΣ	1..1	Reference(QICoreOrganization)	Party responsible for reimbursement	Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization]])
requestor	S	0..1	Reference(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner | http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization | http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)	Party responsible for the claim	S	0..1	Reference(QICore Practitioner | QICoreOrganization | QICorePractitionerRole)	Party responsible for the claim	Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization], CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole]])
request	SΣ	0..1	Reference(http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim)	Id of resource triggering adjudication	SΣ	0..1	Reference(QICoreClaim)	Id of resource triggering adjudication	Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim]]) vs Reference([CanonicalType[http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim]])
outcome	Σ	1..1	code	queued | complete | error | partial Binding: todo (required): The result of the claim processing.	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: todo (example): A code for the party to be reimbursed.		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item	S	0..*	BackboneElement	Adjudication for claim line items	S	0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: todo (example): The adjudication codes. Fixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/adjudication","code":"submitted"}]} (Submitted Amount)	S	1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Fixed Value: {"coding":[{"system":"http://terminology.hl7.org/CodeSystem/adjudication","code":"submitted"}]} (Submitted Amount)
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: todo (example): The adjudication reason codes.		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	0..1	Money	Monetary amount	S	0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	S	1..1	positiveInt	Claim detail instance identifier	S	1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: todo (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: todo (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: todo (example): Program specific reason codes.		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1	date, Period	Date or dates of service or product delivery		0..1	date, Period	Date or dates of service or product delivery
location[x]		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: todo (example): Place of service: pharmacy, school, prison, etc.		0..1	CodeableConcept, Address, Reference(Location)	Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
quantity		0..1	Quantity	Count of products or services		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: todo (example): The code for the teeth, quadrant, sextant and arch.		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: todo (example): The code for the tooth surface and surface combinations.		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: todo (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: todo (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	Quantity	Count of products or services		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: todo (example): Allowable service and product codes.		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: todo (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	Quantity	Count of products or services		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: todo (example): The adjudication codes.	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: todo (example): The type (partial, complete) of the payment.		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: todo (example): Payment Adjustment reason codes.		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: todo (example): For whom funds are to be reserved: (Patient, Provider, None).		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: todo (example): The forms codes.		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: todo (required): The presentation types of notes.		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: todo (preferred): A human language. Additional Bindings Purpose todo Max Binding		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: todo (example): The adjudication error codes.		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format