QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) 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
| Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse | Version: 6.0.0 | |||
| Draft as of 2022-04-20 | Computable Name: QICoreClaimResponse | |||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
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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
| Preauthorization Vision ClaimResponse Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
  status | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
 type | Σ | 1..1 | CodeableConcept | (QI-Core) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization |
 patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services |
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date |
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement |
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) Id of resource triggering adjudication |
 item | 0..* | BackboneElement | (QI-Core) Adjudication for claim line items | |
  adjudication | 1..* | BackboneElement | (QI-Core) Adjudication details | |
 category | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) Monetary amount | |
 detail | ||||
| detailSequence | 1..1 | positiveInt | (QI-Core) Claim detail instance identifier | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard |
| 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 | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
| type | Σ | 1..1 | CodeableConcept | (QI-Core) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization |
| patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services |
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date |
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement |
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) Id of resource triggering adjudication |
| outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| item | 0..* | BackboneElement | (QI-Core) 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 | 1..* | BackboneElement | (QI-Core) Adjudication details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) Monetary amount | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard |
| 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.
| |||||
| 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 | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
| type | Σ | 1..1 | CodeableConcept | (QI-Core) 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 | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization | ||||
| patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services | ||||
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date | ||||
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement | ||||
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |||||
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) 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 | 0..* | BackboneElement | (QI-Core) 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 | 1..* | BackboneElement | (QI-Core) 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 | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) 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 | 1..1 | positiveInt | (QI-Core) 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.
| |||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-errorfrom the FHIR Standard |
| 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() |
This structure is derived from ClaimResponse
Summary
Mandatory: 6 elements (3 nested mandatory elements)
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
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 | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
| type | Σ | 1..1 | CodeableConcept | (QI-Core) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization |
| patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services |
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date |
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement |
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) Id of resource triggering adjudication |
| item | 0..* | BackboneElement | (QI-Core) Adjudication for claim line items | |
| adjudication | 1..* | BackboneElement | (QI-Core) Adjudication details | |
| category | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) Monetary amount | |
| detail | ||||
| detailSequence | 1..1 | positiveInt | (QI-Core) Claim detail instance identifier | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard |
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 | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active |
| type | Σ | 1..1 | CodeableConcept | (QI-Core) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
| use | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization |
| patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services |
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date |
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement |
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) Id of resource triggering adjudication |
| outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
| item | 0..* | BackboneElement | (QI-Core) 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 | 1..* | BackboneElement | (QI-Core) Adjudication details | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) Monetary amount | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard |
| 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.
| |||||
| 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 | ?!Σ | 1..1 | code | (QI-Core) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active | ||||
| type | Σ | 1..1 | CodeableConcept | (QI-Core) 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 | Σ | 1..1 | code | (QI-Core) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization | ||||
| patient | Σ | 1..1 | Reference(QICore Patient) | (QI-Core) The recipient of the products and services | ||||
| created | Σ | 1..1 | dateTime | (QI-Core) Response creation date | ||||
| insurer | Σ | 1..1 | Reference(QICore Organization) | (QI-Core) Party responsible for reimbursement | ||||
| requestor | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI-Core) Party responsible for the claim | |||||
| request | Σ | 0..1 | Reference(QICore Claim) | (QI-Core) 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 | 0..* | BackboneElement | (QI-Core) 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 | 1..* | BackboneElement | (QI-Core) 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 | 1..1 | CodeableConcept | (QI-Core) 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 | 0..1 | Money | (QI-Core) 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 | 1..1 | positiveInt | (QI-Core) 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.
| |||||
| 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 | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.status | required | Fixed Value: activehttp://hl7.org/fhir/ValueSet/fm-status|4.0.1from the FHIR Standard | ||||
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | ||||
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | ||||
| ClaimResponse.use | required | Fixed Value: preauthorizationhttp://hl7.org/fhir/ValueSet/claim-use|4.0.1from the FHIR Standard | ||||
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1from the FHIR Standard | ||||
| ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.category | example | Pattern: submittedhttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | ||||
| ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | ||||
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | ||||
| ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | ||||
| ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | ||||
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | ||||
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | ||||
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | ||||
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | ||||
| ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | ||||
| ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | ||||
| ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1from the FHIR Standard | ||||
| ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| ClaimResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-errorfrom the FHIR Standard |
| 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() |
This structure is derived from ClaimResponse
Summary
Mandatory: 6 elements (3 nested mandatory elements)
Fixed Value: 2 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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