This page is part of the Quality Improvement Core Framework (v6.0.0-ballot: STU6 (v6.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

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Resource Profile: QICore ClaimResponse

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

Usage:

• Examples for this Resource Profile: ClaimResponse/example

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
item	S	0..*	BackboneElement	Adjudication for claim line items
adjudication	S	1..*	BackboneElement	Adjudication details
category	S	1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	S	0..1	Money	Monetary amount
detail
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item	S	0..*	BackboneElement	Adjudication for claim line items
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
modifierExtension	?!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: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	S	0..1	Money	Monetary amount
detail		0..*	BackboneElement	Adjudication for claim details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.item.adjudication.category	example	Pattern: submitted

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	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	error	ClaimResponse	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	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!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: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		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: 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: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		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: 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	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		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: 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	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		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
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		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: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		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
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	Pattern: submitted
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.addItem.productOrService	example	USCLSCodes
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements (3 nested mandatory elements)
Must-Support: 13 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

• QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
• QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
• QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
• QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
• QICore Claim (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim)

Differential View

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
item	S	0..*	BackboneElement	Adjudication for claim line items
adjudication	S	1..*	BackboneElement	Adjudication details
category	S	1..1	CodeableConcept	This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	S	0..1	Money	Monetary amount
detail
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet / Code
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item	S	0..*	BackboneElement	Adjudication for claim line items
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
adjudication	S	1..*	BackboneElement	Adjudication details
modifierExtension	?!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: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
amount	S	0..1	Money	Monetary amount
detail		0..*	BackboneElement	Adjudication for claim details
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.item.adjudication.category	example	Pattern: submitted

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	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	error	ClaimResponse	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	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!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: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient	SΣ	1..1	Reference(QICore Patient)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(QICore Organization)	Party responsible for reimbursement
requestor	S	0..1	Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole)	Party responsible for the claim
request	SΣ	0..1	Reference(QICore Claim)	Id of resource triggering adjudication
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		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
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!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: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: submitted
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence	S	1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		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: 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: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		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: 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	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		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: 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	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		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
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		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: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		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
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	Fixed Value: active
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Fixed Value: preauthorization
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	Pattern: submitted
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.addItem.productOrService	example	USCLSCodes
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements (3 nested mandatory elements)
Must-Support: 13 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

• QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
• QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
• QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
• QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
• QICore Claim (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim)

Other representations of profile: CSV, Excel, Schematron