Profile_R2_ClaimResponse_R4B - Definitions - Extensions for Using Data Elements from FHIR DSTU2 in FHIR R4B v0.1.0

Is Modifier false

Must Support false

Summary true

4. ClaimResponse.meta

Definition

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

Short Metadata about the resource

Control 0..1

Meta

Is Modifier false

Must Support false

Summary true

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

6. ClaimResponse.meta.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

8. ClaimResponse.meta.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

This element introduces a set of slices on ClaimResponse.meta.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

10. ClaimResponse.meta.extension:meta

Slice Name meta

Definition

DSTU2: ClaimResponse.meta additional types (Meta) additional types from child elements (lastUpdated, profile, security, tag, versionId)

Short DSTU2: meta additional types

Comments

Element ClaimResponse.meta is mapped to FHIR R4B element ClaimResponse.meta as SourceIsBroaderThanTarget. The mappings for ClaimResponse.meta do not cover the following types: Meta. The mappings for ClaimResponse.meta do not cover the following types based on type expansion: lastUpdated, profile, security, tag, versionId.

Control 0..1

Type Extension(DSTU2: meta additional types) (Complex Extension)

Is Modifier false

12. ClaimResponse.meta.versionId

Definition

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

Short Version specific identifier

Comments

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

14. ClaimResponse.meta.lastUpdated

Definition

When the resource last changed - e.g. when the version changed.

Short When the resource version last changed

Comments

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

Control 0..1

instant

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

16. ClaimResponse.meta.source

Definition

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

Short Identifies where the resource comes from

Comments

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

18. ClaimResponse.meta.profile

Definition

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

Short Profiles this resource claims to conform to

Comments

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Control 0..*

Type canonical(StructureDefinition)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

20. ClaimResponse.meta.security

Definition

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

Short Security Labels applied to this resource

Comments

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Control 0..*

Binding Unless not suitable, these codes SHALL be taken from All Security Labels
(extensible to http://hl7.org/fhir/ValueSet/security-labels|4.3.0)

Is Modifier false

Summary true

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

22. ClaimResponse.meta.tag

Definition

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

Short Tags applied to this resource

Comments

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Control 0..*

Binding For example codes, see CommonTags
(example to http://hl7.org/fhir/ValueSet/common-tags|4.3.0)

Is Modifier false

Summary true

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

24. ClaimResponse.implicitRules

Definition

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

Short A set of rules under which this content was created

Comments

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

Control 0..1

Is Modifier true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

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

26. ClaimResponse.language

Definition

The base language in which the resource is written.

Short Language of the resource content

Comments

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

Control 0..1

The codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages|4.3.0)

IETF language tag

Additional Bindings

Purpose

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

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

28. ClaimResponse.text

Definition

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

Short Text summary of the resource, for human interpretation

Comments

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

Control 0..1

Narrative

Is Modifier false

Must Support false

Summary false

Alternate Names narrative, html, xhtml, display

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

30. ClaimResponse.text.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

32. ClaimResponse.text.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.text.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

34. ClaimResponse.text.extension:text

Slice Name text

Definition

DSTU2: ClaimResponse.text additional types (Narrative) additional types from child elements (div, status)

Short DSTU2: text additional types

Comments

Element ClaimResponse.text is mapped to FHIR R4B element ClaimResponse.text as SourceIsBroaderThanTarget. The mappings for ClaimResponse.text do not cover the following types: Narrative. The mappings for ClaimResponse.text do not cover the following types based on type expansion: div, status. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Control 0..1

Type Extension(DSTU2: text additional types) (Complex Extension)

Is Modifier false

36. ClaimResponse.text.status

Definition

The status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data.

Short generated | extensions | additional | empty

Control 1..1

Binding The codes SHALL be taken from NarrativeStatus
(required to http://hl7.org/fhir/ValueSet/narrative-status|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

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

38. ClaimResponse.text.div

Definition

The actual narrative content, a stripped down version of XHTML.

Short Limited xhtml content

Comments

The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.

Control 1..1

xhtml

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary false

Invariants ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
txt-1: The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes (htmlChecks())
txt-2: The narrative SHALL have some non-whitespace content (htmlChecks())

40. ClaimResponse.contained

Definition

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

Short Contained, inline Resources

Comments

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

Control 0..*

Resource

Is Modifier false

Must Support false

Summary false

Alternate Names inline resources, anonymous resources, contained resources

Invariants dom-r4b: Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems (($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic))

42. ClaimResponse.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Must Support false

Summary false

This element introduces a set of slices on ClaimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

44. ClaimResponse.extension:ruleset

Slice Name ruleset

Definition

DSTU2: ClaimResponse.ruleset (new:Coding)

Short DSTU2: Resource version (new)

Comments

Element ClaimResponse.ruleset has a context of ClaimResponse based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.ruleset has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Resource version (new)) (Extension Type: Coding)

Is Modifier false

Must Support false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())

46. ClaimResponse.extension:originalRuleset

Slice Name originalRuleset

Definition

DSTU2: ClaimResponse.originalRuleset (new:Coding)

Short DSTU2: Original version (new)

Comments

Element ClaimResponse.originalRuleset has a context of ClaimResponse based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.originalRuleset has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Original version (new)) (Extension Type: Coding)

Is Modifier false

Must Support false

Summary false

48. ClaimResponse.extension:unallocDeductable

Slice Name unallocDeductable

Definition

DSTU2: ClaimResponse.unallocDeductable (new:Quantity[Money])

Short DSTU2: Unallocated deductible (new)

Comments

Element ClaimResponse.unallocDeductable has a context of ClaimResponse based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.unallocDeductable has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Unallocated deductible (new)) (Extension Type: Money)

Is Modifier false

Must Support false

Summary false

50. ClaimResponse.modifierExtension

Definition

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

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

Short Extensions that cannot be ignored

Comments

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

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them

Must Support false

Summary false

Requirements

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

Alternate Names extensions, user content

52. ClaimResponse.identifier

Definition

A unique identifier assigned to this claim response.

Short Business Identifier for a claim response

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

Allows claim responses to be distinguished and referenced.

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

54. ClaimResponse.identifier.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

56. ClaimResponse.identifier.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

58. ClaimResponse.identifier.extension:identifier

Slice Name identifier

Definition

DSTU2: ClaimResponse.identifier additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)

Short DSTU2: Response number additional types

Comments

Element ClaimResponse.identifier is mapped to FHIR R4B element ClaimResponse.identifier as SourceIsBroaderThanTarget. The mappings for ClaimResponse.identifier do not cover the following types: Identifier. The mappings for ClaimResponse.identifier do not cover the following types based on type expansion: assigner, period, system, type, use, value.

Control 0..*

Type Extension(DSTU2: Response number additional types) (Extension Type: Identifier)

Is Modifier false

Summary false

60. ClaimResponse.identifier.use

Definition

The purpose of this identifier.

Short usual | official | temp | secondary | old (If known)

Comments

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

Control 0..1

Binding The codes SHALL be taken from IdentifierUse
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.3.0)

Is Modifier true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

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

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

62. ClaimResponse.identifier.type

Definition

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

Short Description of identifier

Comments

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

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from Identifier Type Codes
(extensible to http://hl7.org/fhir/ValueSet/identifier-type|4.3.0)

Is Modifier false

Summary true

Requirements

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

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

64. ClaimResponse.identifier.system

Definition

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

Short The namespace for the identifier value

Comments

Identifier.system is always case sensitive.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

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

Example General: http://www.acme.com/identifiers/patient

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

66. ClaimResponse.identifier.value

Definition

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

Short The value that is unique

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Example General: 123456

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

68. ClaimResponse.identifier.period

Definition

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

Short Time period when id is/was valid for use

Control 0..1

Period

Is Modifier false

Summary true

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

70. ClaimResponse.identifier.assigner

Definition

Organization that issued/manages the identifier.

Short Organization that issued id (may be just text)

Comments

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

Control 0..1

Type Reference(Organization)

Is Modifier false

Summary true

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

72. ClaimResponse.status

Definition

The status of the resource instance.

Short active | cancelled | draft | entered-in-error

Comments

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

Control 1..1

The codes SHALL be taken from FinancialResourceStatusCodes
(required to http://hl7.org/fhir/ValueSet/fm-status|4.3.0)

A code specifying the state of the resource instance.

Is Modifier true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

74. ClaimResponse.type

Definition

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

Short More granular claim type

Comments

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

Control 1..1

Unless not suitable, these codes SHALL be taken from ClaimTypeCodes
(extensible to http://hl7.org/fhir/ValueSet/claim-type|4.3.0)

The type or discipline-style of the claim.

Is Modifier false

Must Support false

Summary true

Requirements

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

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

76. ClaimResponse.subType

Definition

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

Short More granular claim type

Comments

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

Control 0..1

For example codes, see ExampleClaimSubTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-subtype|4.3.0)

A more granular claim typecode.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

78. ClaimResponse.use

Definition

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

Short claim | preauthorization | predetermination

Control 1..1

The codes SHALL be taken from Use
(required to http://hl7.org/fhir/ValueSet/claim-use|4.3.0)

Claim, preauthorization, predetermination.

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

80. ClaimResponse.patient

Definition

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

Short The recipient of the products and services

Control 1..1

Type Reference(Patient)

Is Modifier false

Must Support false

Summary true

Requirements

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

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

82. ClaimResponse.created

Definition

The date this resource was created.

Short Response creation date

Control 1..1

dateTime

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

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

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

84. ClaimResponse.insurer

Definition

The party responsible for authorization, adjudication and reimbursement.

Short Party responsible for reimbursement

Control 1..1

Type Reference(Organization)

Is Modifier false

Must Support false

Summary true

Requirements

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

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

86. ClaimResponse.insurer.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

88. ClaimResponse.insurer.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.insurer.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

90. ClaimResponse.insurer.extension:organization

Slice Name organization

Definition

DSTU2: ClaimResponse.organization additional types from child elements (display, reference)

Short DSTU2: Insurer additional types

Comments

Element ClaimResponse.organization is mapped to FHIR R4B element ClaimResponse.insurer as SourceIsBroaderThanTarget. The mappings for ClaimResponse.organization do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.organization with unmapped reference targets: Organization.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

92. ClaimResponse.insurer.reference

Definition

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

Short Literal reference, Relative, internal or absolute URL

Comments

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

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

94. ClaimResponse.insurer.type

Definition

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

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

Short Type the reference refers to (e.g. "Patient")

Comments

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

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

96. ClaimResponse.insurer.identifier

Definition

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

Short Logical reference, when literal reference is not known

Comments

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

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

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

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

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

98. ClaimResponse.insurer.display

Definition

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

Short Text alternative for the resource

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

100. ClaimResponse.requestor

Definition

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

Short Party responsible for the claim

Comments

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

Control 0..1

Type Reference(Practitioner, PractitionerRole, Organization)

Is Modifier false

Must Support false

Summary false

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

102. ClaimResponse.requestor.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

104. ClaimResponse.requestor.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.requestor.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

106. ClaimResponse.requestor.extension:requestProvider

Slice Name requestProvider

Definition

DSTU2: ClaimResponse.requestProvider additional types from child elements (display, reference)

Short DSTU2: Responsible practitioner additional types

Comments

Element ClaimResponse.requestProvider is mapped to FHIR R4B element ClaimResponse.requestor as RelatedTo. The mappings for ClaimResponse.requestProvider do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.requestProvider with unmapped reference targets: Practitioner.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

108. ClaimResponse.requestor.extension:requestOrganization

Slice Name requestOrganization

Definition

DSTU2: ClaimResponse.requestOrganization additional types from child elements (display, reference)

Short DSTU2: Responsible organization additional types

Comments

Element ClaimResponse.requestOrganization is mapped to FHIR R4B element ClaimResponse.requestor as SourceIsBroaderThanTarget. The mappings for ClaimResponse.requestOrganization do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.requestOrganization with unmapped reference targets: Organization.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

110. ClaimResponse.requestor.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

112. ClaimResponse.requestor.type

Definition

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

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

114. ClaimResponse.requestor.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

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

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

116. ClaimResponse.requestor.display

Definition

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

Short Text alternative for the resource

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

118. ClaimResponse.request

Definition

Original request resource reference.

Short Id of resource triggering adjudication

Control 0..1

Type Reference(Claim)

Is Modifier false

Must Support false

Summary true

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

120. ClaimResponse.request.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

122. ClaimResponse.request.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.request.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

124. ClaimResponse.request.extension:request

Slice Name request

Definition

DSTU2: ClaimResponse.request additional types from child elements (display, reference)

Short DSTU2: request additional types

Comments

Element ClaimResponse.request is mapped to FHIR R4B element ClaimResponse.request as SourceIsBroaderThanTarget. The mappings for ClaimResponse.request do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.request with unmapped reference targets: Claim.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

126. ClaimResponse.request.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

128. ClaimResponse.request.type

Definition

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

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

130. ClaimResponse.request.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

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

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

132. ClaimResponse.request.display

Definition

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

Short Text alternative for the resource

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

134. ClaimResponse.outcome

Definition

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

Short queued | complete | error | partial

Comments

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

Control 1..1

The codes SHALL be taken from RemittanceOutcome
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0)

The result of the claim processing.

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary true

Requirements

To advise the requestor of an overall processing outcome.

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

136. ClaimResponse.disposition

Definition

A human readable description of the status of the adjudication.

Short Disposition Message

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Provided for user display.

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

138. ClaimResponse.preAuthRef

Definition

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

Short Preauthorization reference

Comments

This value is only present on preauthorization adjudications.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

140. ClaimResponse.preAuthPeriod

Definition

The time frame during which this authorization is effective.

Short Preauthorization reference effective period

Control 0..1

Period

Is Modifier false

Must Support false

Summary false

Requirements

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

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

142. ClaimResponse.payeeType

Definition

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

Short Party to be paid any benefits payable

Control 0..1

For example codes, see Claim Payee Type Codes
(example to http://hl7.org/fhir/ValueSet/payeetype|4.3.0)

A code for the party to be reimbursed.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

144. ClaimResponse.item

Definition

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

Short Adjudication for claim line items

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The adjudication for items provided on the claim.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

146. ClaimResponse.item.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

148. ClaimResponse.item.extension

Definition

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

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

150. ClaimResponse.item.modifierExtension

Definition

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

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

152. ClaimResponse.item.itemSequence

Definition

A number to uniquely reference the claim item entries.

Short Claim item instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

154. ClaimResponse.item.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

156. ClaimResponse.item.adjudication

Definition

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

Short Adjudication details

Control 1..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

158. ClaimResponse.item.adjudication.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

160. ClaimResponse.item.adjudication.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

162. ClaimResponse.item.adjudication.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

164. ClaimResponse.item.adjudication.category

Definition

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

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

166. ClaimResponse.item.adjudication.reason

Definition

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

Short Explanation of adjudication outcome

Comments

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

Control 0..1

For example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.3.0)

The adjudication reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

To support understanding of variance from adjudication expectations.

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

168. ClaimResponse.item.adjudication.amount

Definition

Monetary amount associated with the category.

Short Monetary amount

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Most adjuciation categories convey a monetary amount.

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

170. ClaimResponse.item.adjudication.value

Definition

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

Short Non-monetary value

Comments

For example: eligible percentage or co-payment percentage.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Some adjudication categories convey a percentage or a fixed value.

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

172. ClaimResponse.item.detail

Definition

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

Short Adjudication for claim details

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The adjudication for details provided on the claim.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

174. ClaimResponse.item.detail.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

176. ClaimResponse.item.detail.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

178. ClaimResponse.item.detail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

180. ClaimResponse.item.detail.detailSequence

Definition

A number to uniquely reference the claim detail entry.

Short Claim detail instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

182. ClaimResponse.item.detail.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

184. ClaimResponse.item.detail.adjudication

Definition

The adjudication results.

Short Detail level adjudication details

Control 1..*

Is Modifier false

Must Support false

Summary false

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

186. ClaimResponse.item.detail.adjudication.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

188. ClaimResponse.item.detail.adjudication.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.item.detail.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

190. ClaimResponse.item.detail.adjudication.extension:amount

Slice Name amount

Definition

DSTU2: ClaimResponse.item.detail.adjudication.amount (new:Quantity[Money])

Short DSTU2: Monetary amount (new)

Comments

Element ClaimResponse.item.detail.adjudication.amount has a context of ClaimResponse.item.detail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.item.detail.adjudication.amount has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Monetary amount (new)) (Extension Type: Money)

Is Modifier false

Summary false

192. ClaimResponse.item.detail.adjudication.extension:value

Slice Name value

Definition

DSTU2: ClaimResponse.item.detail.adjudication.value (new:decimal)

Short DSTU2: Non-monetary value (new)

Comments

Element ClaimResponse.item.detail.adjudication.value has a context of ClaimResponse.item.detail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.item.detail.adjudication.value has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Non-monetary value (new)) (Extension Type: decimal)

Is Modifier false

Summary false

194. ClaimResponse.item.detail.adjudication.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

196. ClaimResponse.item.detail.adjudication.category

Definition

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

198. ClaimResponse.item.detail.adjudication.reason

Definition

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

Short Explanation of adjudication outcome

Comments

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

Control 0..1

For example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.3.0)

The adjudication reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

To support understanding of variance from adjudication expectations.

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

200. ClaimResponse.item.detail.adjudication.amount

Definition

Monetary amount associated with the category.

Short Monetary amount

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Most adjuciation categories convey a monetary amount.

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

202. ClaimResponse.item.detail.adjudication.value

Definition

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

Short Non-monetary value

Comments

For example: eligible percentage or co-payment percentage.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Some adjudication categories convey a percentage or a fixed value.

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

204. ClaimResponse.item.detail.subDetail

Definition

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

Short Adjudication for claim sub-details

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

The adjudication for sub-details provided on the claim.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

206. ClaimResponse.item.detail.subDetail.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

208. ClaimResponse.item.detail.subDetail.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

210. ClaimResponse.item.detail.subDetail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

212. ClaimResponse.item.detail.subDetail.subDetailSequence

Definition

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

Short Claim sub-detail instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

214. ClaimResponse.item.detail.subDetail.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

216. ClaimResponse.item.detail.subDetail.adjudication

Definition

The adjudication results.

Short Subdetail level adjudication details

Control 0..*

Is Modifier false

Must Support false

Summary false

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

218. ClaimResponse.item.detail.subDetail.adjudication.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

220. ClaimResponse.item.detail.subDetail.adjudication.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.item.detail.subDetail.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

222. ClaimResponse.item.detail.subDetail.adjudication.extension:amount

Slice Name amount

Definition

DSTU2: ClaimResponse.item.detail.subDetail.adjudication.amount (new:Quantity[Money])

Short DSTU2: Monetary amount (new)

Comments

Element ClaimResponse.item.detail.subDetail.adjudication.amount has a context of ClaimResponse.item.detail.subDetail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.item.detail.subDetail.adjudication.amount has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Monetary amount (new)) (Extension Type: Money)

Is Modifier false

Summary false

224. ClaimResponse.item.detail.subDetail.adjudication.extension:value

Slice Name value

Definition

DSTU2: ClaimResponse.item.detail.subDetail.adjudication.value (new:decimal)

Short DSTU2: Non-monetary value (new)

Comments

Element ClaimResponse.item.detail.subDetail.adjudication.value has a context of ClaimResponse.item.detail.subDetail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.item.detail.subDetail.adjudication.value has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Non-monetary value (new)) (Extension Type: decimal)

Is Modifier false

Summary false

226. ClaimResponse.item.detail.subDetail.adjudication.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

228. ClaimResponse.item.detail.subDetail.adjudication.category

Definition

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

230. ClaimResponse.item.detail.subDetail.adjudication.reason

Definition

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

Short Explanation of adjudication outcome

Comments

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

Control 0..1

For example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.3.0)

The adjudication reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

To support understanding of variance from adjudication expectations.

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

232. ClaimResponse.item.detail.subDetail.adjudication.amount

Definition

Monetary amount associated with the category.

Short Monetary amount

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Most adjuciation categories convey a monetary amount.

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

234. ClaimResponse.item.detail.subDetail.adjudication.value

Definition

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

Short Non-monetary value

Comments

For example: eligible percentage or co-payment percentage.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Some adjudication categories convey a percentage or a fixed value.

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

236. ClaimResponse.addItem

Definition

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

Short Insurer added line items

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

238. ClaimResponse.addItem.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

240. ClaimResponse.addItem.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.addItem.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

242. ClaimResponse.addItem.extension:fee

Slice Name fee

Definition

DSTU2: ClaimResponse.addItem.fee (new:Quantity[Money])

Short DSTU2: Professional fee or Product charge (new)

Comments

Element ClaimResponse.addItem.fee has a context of ClaimResponse.addItem based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.fee has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Professional fee or Product charge (new)) (Extension Type: Money)

Is Modifier false

Summary false

244. ClaimResponse.addItem.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

246. ClaimResponse.addItem.itemSequence

Definition

Claim items which this service line is intended to replace.

Short Item sequence number

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Provides references to the claim items.

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

248. ClaimResponse.addItem.detailSequence

Definition

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

Short Detail sequence number

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Provides references to the claim details within the claim item.

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

250. ClaimResponse.addItem.subdetailSequence

Definition

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

Short Subdetail sequence number

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

252. ClaimResponse.addItem.provider

Definition

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

Short Authorized providers

Control 0..*

Type Reference(Practitioner, PractitionerRole, Organization)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

254. ClaimResponse.addItem.productOrService

Definition

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

Short Billing, service, product, or drug code

Comments

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

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

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

256. ClaimResponse.addItem.modifier

Definition

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

Short Service/Product billing modifiers

Comments

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

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

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

Is Modifier false

Must Support false

Summary false

Requirements

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

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

258. ClaimResponse.addItem.programCode

Definition

Identifies the program under which this may be recovered.

Short Program the product or service is provided under

Comments

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

Control 0..*

For example codes, see ExampleProgramReasonCodes
(example to http://hl7.org/fhir/ValueSet/ex-program-code|4.3.0)

Program specific reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

260. ClaimResponse.addItem.serviced[x]

Definition

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

Short Date or dates of service or product delivery

Control 0..1

Type Choice of: date, Period

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

262. ClaimResponse.addItem.location[x]

Definition

Where the product or service was provided.

Short Place of service or where product was supplied

Control 0..1

For example codes, see ExampleServicePlaceCodes
(example to http://hl7.org/fhir/ValueSet/service-place|4.3.0)

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

Type Choice of: CodeableConcept, Address, Reference(Location)

[x] Note SeeChoice of Data Typesfor further information about how to use [x]

Is Modifier false

Must Support false

Summary false

Requirements

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

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

264. ClaimResponse.addItem.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

266. ClaimResponse.addItem.unitPrice

Definition

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

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

268. ClaimResponse.addItem.factor

Definition

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

Short Price scaling factor

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

270. ClaimResponse.addItem.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

272. ClaimResponse.addItem.bodySite

Definition

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

Short Anatomical location

Comments

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

Control 0..1

For example codes, see OralSiteCodes
(example to http://hl7.org/fhir/ValueSet/tooth|4.3.0)

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

Is Modifier false

Must Support false

Summary false

Requirements

Allows insurer to validate specific procedures.

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

274. ClaimResponse.addItem.subSite

Definition

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

Short Anatomical sub-location

Control 0..*

For example codes, see SurfaceCodes
(example to http://hl7.org/fhir/ValueSet/surface|4.3.0)

The code for the tooth surface and surface combinations.

Is Modifier false

Must Support false

Summary false

Requirements

Allows insurer to validate specific procedures.

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

276. ClaimResponse.addItem.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

278. ClaimResponse.addItem.adjudication

Definition

The adjudication results.

Short Added items adjudication

Control 1..*

Is Modifier false

Must Support false

Summary false

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

280. ClaimResponse.addItem.adjudication.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

282. ClaimResponse.addItem.adjudication.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.addItem.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

284. ClaimResponse.addItem.adjudication.extension:amount

Slice Name amount

Definition

DSTU2: ClaimResponse.addItem.adjudication.amount (new:Quantity[Money])

Short DSTU2: Monetary amount (new)

Comments

Element ClaimResponse.addItem.adjudication.amount has a context of ClaimResponse.addItem.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.adjudication.amount has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Monetary amount (new)) (Extension Type: Money)

Is Modifier false

Summary false

286. ClaimResponse.addItem.adjudication.extension:value

Slice Name value

Definition

DSTU2: ClaimResponse.addItem.adjudication.value (new:decimal)

Short DSTU2: Non-monetary value (new)

Comments

Element ClaimResponse.addItem.adjudication.value has a context of ClaimResponse.addItem.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.adjudication.value has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Non-monetary value (new)) (Extension Type: decimal)

Is Modifier false

Summary false

288. ClaimResponse.addItem.adjudication.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

290. ClaimResponse.addItem.adjudication.category

Definition

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

292. ClaimResponse.addItem.adjudication.reason

Definition

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

Short Explanation of adjudication outcome

Comments

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

Control 0..1

For example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.3.0)

The adjudication reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

To support understanding of variance from adjudication expectations.

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

294. ClaimResponse.addItem.adjudication.amount

Definition

Monetary amount associated with the category.

Short Monetary amount

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Most adjuciation categories convey a monetary amount.

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

296. ClaimResponse.addItem.adjudication.value

Definition

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

Short Non-monetary value

Comments

For example: eligible percentage or co-payment percentage.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Some adjudication categories convey a percentage or a fixed value.

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

298. ClaimResponse.addItem.detail

Definition

The second-tier service adjudications for payor added services.

Short Insurer added line details

Control 0..*

Is Modifier false

Must Support false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

300. ClaimResponse.addItem.detail.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

302. ClaimResponse.addItem.detail.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.addItem.detail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

304. ClaimResponse.addItem.detail.extension:fee

Slice Name fee

Definition

DSTU2: ClaimResponse.addItem.detail.fee (new:Quantity[Money])

Short DSTU2: Professional fee or Product charge (new)

Comments

Element ClaimResponse.addItem.detail.fee has a context of ClaimResponse.addItem.detail based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.detail.fee has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Professional fee or Product charge (new)) (Extension Type: Money)

Is Modifier false

Summary false

306. ClaimResponse.addItem.detail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

308. ClaimResponse.addItem.detail.productOrService

Definition

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

Short Billing, service, product, or drug code

Comments

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

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

310. ClaimResponse.addItem.detail.modifier

Definition

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

Short Service/Product billing modifiers

Comments

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

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

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

Is Modifier false

Must Support false

Summary false

Requirements

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

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

312. ClaimResponse.addItem.detail.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

314. ClaimResponse.addItem.detail.unitPrice

Definition

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

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

316. ClaimResponse.addItem.detail.factor

Definition

Short Price scaling factor

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

318. ClaimResponse.addItem.detail.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

320. ClaimResponse.addItem.detail.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

322. ClaimResponse.addItem.detail.adjudication

Definition

The adjudication results.

Short Added items detail adjudication

Control 1..*

Is Modifier false

Must Support false

Summary false

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

324. ClaimResponse.addItem.detail.adjudication.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

326. ClaimResponse.addItem.detail.adjudication.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.addItem.detail.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

328. ClaimResponse.addItem.detail.adjudication.extension:amount

Slice Name amount

Definition

DSTU2: ClaimResponse.addItem.detail.adjudication.amount (new:Quantity[Money])

Short DSTU2: Monetary amount (new)

Comments

Element ClaimResponse.addItem.detail.adjudication.amount has a context of ClaimResponse.addItem.detail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.detail.adjudication.amount has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Monetary amount (new)) (Extension Type: Money)

Is Modifier false

Summary false

330. ClaimResponse.addItem.detail.adjudication.extension:value

Slice Name value

Definition

DSTU2: ClaimResponse.addItem.detail.adjudication.value (new:decimal)

Short DSTU2: Non-monetary value (new)

Comments

Element ClaimResponse.addItem.detail.adjudication.value has a context of ClaimResponse.addItem.detail.adjudication based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.addItem.detail.adjudication.value has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Non-monetary value (new)) (Extension Type: decimal)

Is Modifier false

Summary false

332. ClaimResponse.addItem.detail.adjudication.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

334. ClaimResponse.addItem.detail.adjudication.category

Definition

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

336. ClaimResponse.addItem.detail.adjudication.reason

Definition

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

Short Explanation of adjudication outcome

Comments

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

Control 0..1

For example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.3.0)

The adjudication reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

To support understanding of variance from adjudication expectations.

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

338. ClaimResponse.addItem.detail.adjudication.amount

Definition

Monetary amount associated with the category.

Short Monetary amount

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Most adjuciation categories convey a monetary amount.

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

340. ClaimResponse.addItem.detail.adjudication.value

Definition

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

Short Non-monetary value

Comments

For example: eligible percentage or co-payment percentage.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Some adjudication categories convey a percentage or a fixed value.

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

342. ClaimResponse.addItem.detail.subDetail

Definition

The third-tier service adjudications for payor added services.

Short Insurer added line items

Control 0..*

Is Modifier false

Must Support false

Summary false

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

344. ClaimResponse.addItem.detail.subDetail.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

346. ClaimResponse.addItem.detail.subDetail.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

348. ClaimResponse.addItem.detail.subDetail.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

350. ClaimResponse.addItem.detail.subDetail.productOrService

Definition

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

Short Billing, service, product, or drug code

Comments

Control 1..1

For example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls|4.3.0)

Allowable service and product codes.

Is Modifier false

Must Support false

Summary false

Requirements

Necessary to state what was provided or done.

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

352. ClaimResponse.addItem.detail.subDetail.modifier

Definition

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

Short Service/Product billing modifiers

Comments

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

Control 0..*

For example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.3.0)

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

Is Modifier false

Must Support false

Summary false

Requirements

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

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

354. ClaimResponse.addItem.detail.subDetail.quantity

Definition

The number of repetitions of a service or product.

Short Count of products or services

Control 0..1

Type Quantity(SimpleQuantity)

Is Modifier false

Must Support false

Summary false

Requirements

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

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

356. ClaimResponse.addItem.detail.subDetail.unitPrice

Definition

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

Short Fee, charge or cost per item

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

358. ClaimResponse.addItem.detail.subDetail.factor

Definition

Short Price scaling factor

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

360. ClaimResponse.addItem.detail.subDetail.net

Definition

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

Short Total item cost

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

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

362. ClaimResponse.addItem.detail.subDetail.noteNumber

Definition

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

Short Applicable note numbers

Control 0..*

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

364. ClaimResponse.addItem.detail.subDetail.adjudication

Definition

The adjudication results.

Short Added items detail adjudication

Control 1..*

Type Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication

Is Modifier false

Must Support false

Summary false

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

366. ClaimResponse.adjudication

Definition

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

Short Header-level adjudication

Control 0..*

Type Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication

Is Modifier false

Must Support false

Summary false

Requirements

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

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

368. ClaimResponse.total

Definition

Categorized monetary totals for the adjudication.

Short Adjudication totals

Comments

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

Control 0..*

Is Modifier false

Must Support false

Summary true

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

370. ClaimResponse.total.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

372. ClaimResponse.total.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

374. ClaimResponse.total.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

376. ClaimResponse.total.category

Definition

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

Short Type of adjudication information

Comments

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

Control 1..1

For example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication|4.3.0)

The adjudication codes.

Is Modifier false

Must Support false

Summary true

Requirements

Needed to convey the type of total provided.

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

378. ClaimResponse.total.amount

Definition

Monetary total amount associated with the category.

Short Financial total for the category

Control 1..1

Is Modifier false

Must Support false

Summary true

Requirements

Needed to convey the total monetary amount.

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

380. ClaimResponse.payment

Definition

Payment details for the adjudication of the claim.

Short Payment Details

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

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

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

382. ClaimResponse.payment.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

384. ClaimResponse.payment.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

386. ClaimResponse.payment.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

388. ClaimResponse.payment.type

Definition

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

Short Partial or complete payment

Control 1..1

For example codes, see ExamplePaymentTypeCodes
(example to http://hl7.org/fhir/ValueSet/ex-paymenttype|4.3.0)

The type (partial, complete) of the payment.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

390. ClaimResponse.payment.adjustment

Definition

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

Short Payment adjustment for non-claim issues

Comments

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

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

To advise the requestor of adjustments applied to the payment.

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

392. ClaimResponse.payment.adjustmentReason

Definition

Reason for the payment adjustment.

Short Explanation for the adjustment

Control 0..1

For example codes, see PaymentAdjustmentReasonCodes
(example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.3.0)

Payment Adjustment reason codes.

Is Modifier false

Must Support false

Summary false

Requirements

Needed to clarify the monetary adjustment.

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

394. ClaimResponse.payment.date

Definition

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

Short Expected date of payment

Control 0..1

date

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

To advise the payee when payment can be expected.

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

396. ClaimResponse.payment.amount

Definition

Benefits payable less any payment adjustment.

Short Payable amount after adjustment

Control 1..1

Is Modifier false

Must Support false

Summary false

Requirements

Needed to provide the actual payment amount.

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

398. ClaimResponse.payment.identifier

Definition

Issuer's unique identifier for the payment instrument.

Short Business identifier for the payment

Comments

For example: EFT number or check number.

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Must Support false

Summary false

Requirements

Enable the receiver to reconcile when payment received.

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

400. ClaimResponse.payment.identifier.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

402. ClaimResponse.payment.identifier.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.payment.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

404. ClaimResponse.payment.identifier.extension:paymentRef

Slice Name paymentRef

Definition

DSTU2: ClaimResponse.paymentRef additional types (Identifier) additional types from child elements (assigner, period, system, type, use, value)

Short DSTU2: Payment identifier additional types

Comments

Element ClaimResponse.paymentRef is mapped to FHIR R4B element ClaimResponse.payment.identifier as SourceIsBroaderThanTarget. The mappings for ClaimResponse.paymentRef do not cover the following types: Identifier. The mappings for ClaimResponse.paymentRef do not cover the following types based on type expansion: assigner, period, system, type, use, value.

Control 0..1

Type Extension(DSTU2: Payment identifier additional types) (Extension Type: Identifier)

Is Modifier false

Summary false

406. ClaimResponse.payment.identifier.use

Definition

The purpose of this identifier.

Short usual | official | temp | secondary | old (If known)

Comments

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

Control 0..1

Binding The codes SHALL be taken from IdentifierUse
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.3.0)

Is Modifier true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

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

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

408. ClaimResponse.payment.identifier.type

Definition

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

Short Description of identifier

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from Identifier Type Codes
(extensible to http://hl7.org/fhir/ValueSet/identifier-type|4.3.0)

Is Modifier false

Summary true

Requirements

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

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

410. ClaimResponse.payment.identifier.system

Definition

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

Short The namespace for the identifier value

Comments

Identifier.system is always case sensitive.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

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

Example General: http://www.acme.com/identifiers/patient

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

412. ClaimResponse.payment.identifier.value

Definition

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

Short The value that is unique

Comments

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Example General: 123456

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

414. ClaimResponse.payment.identifier.period

Definition

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

Short Time period when id is/was valid for use

Control 0..1

Period

Is Modifier false

Summary true

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

416. ClaimResponse.payment.identifier.assigner

Definition

Organization that issued/manages the identifier.

Short Organization that issued id (may be just text)

Comments

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

Control 0..1

Type Reference(Organization)

Is Modifier false

Summary true

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

418. ClaimResponse.fundsReserve

Definition

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

Short Funds reserved status

Comments

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

Control 0..1

For example codes, see Funds Reservation Codes
(example to http://hl7.org/fhir/ValueSet/fundsreserve|4.3.0)

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

Is Modifier false

Must Support false

Summary false

Requirements

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

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

420. ClaimResponse.formCode

Definition

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

Short Printed form identifier

Comments

May be needed to identify specific jurisdictional forms.

Control 0..1

For example codes, see Form Codes
(example to http://hl7.org/fhir/ValueSet/forms|4.3.0)

The forms codes.

Is Modifier false

Must Support false

Summary false

Requirements

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

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

422. ClaimResponse.formCode.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

424. ClaimResponse.formCode.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.formCode.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

426. ClaimResponse.formCode.extension:form

Slice Name form

Definition

DSTU2: ClaimResponse.form

Short DSTU2: Printed Form Identifier

Comments

Element ClaimResponse.form is mapped to FHIR R4B element ClaimResponse.formCode as SourceIsNarrowerThanTarget.

Control 0..1

Type Extension(DSTU2: Printed Form Identifier) (Extension Type: Coding)

Is Modifier false

Summary false

428. ClaimResponse.formCode.coding

Definition

A reference to a code defined by a terminology system.

Short Code defined by a terminology system

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control 0..*

Is Modifier false

Summary true

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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

430. ClaimResponse.formCode.text

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short Plain text representation of the concept

Comments

Very often the text is the same as a displayName of one of the codings.

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

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

432. ClaimResponse.form

Definition

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

Short Printed reference or actual form

Comments

Needed to permit insurers to include the actual form.

Control 0..1

Attachment

Is Modifier false

Must Support false

Summary false

Requirements

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

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

434. ClaimResponse.processNote

Definition

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

Short Note concerning adjudication

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

Provides the insurer specific textual explanations associated with the processing.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

436. ClaimResponse.processNote.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

438. ClaimResponse.processNote.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

440. ClaimResponse.processNote.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

442. ClaimResponse.processNote.number

Definition

A number to uniquely identify a note entry.

Short Note instance identifier

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Necessary to provide a mechanism to link from adjudications.

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

444. ClaimResponse.processNote.type

Definition

The business purpose of the note text.

Short display | print | printoper

Control 0..1

The codes SHALL be taken from NoteType
(required to http://hl7.org/fhir/ValueSet/note-type|4.3.0)

The presentation types of notes.

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

To convey the expectation for when the text is used.

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

446. ClaimResponse.processNote.type.id

Definition

unique id for the element within a resource (for internal references)

Short xml:id (or equivalent in JSON)

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

448. ClaimResponse.processNote.type.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.processNote.type.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

450. ClaimResponse.processNote.type.extension:type

Slice Name type

Definition

DSTU2: ClaimResponse.note.type additional types (Coding) additional types from child elements (userSelected)

Short DSTU2: type additional types

Comments

Element ClaimResponse.note.type is mapped to FHIR R4B element ClaimResponse.processNote.type as RelatedTo. The mappings for ClaimResponse.note.type do not cover the following types: Coding. The mappings for ClaimResponse.note.type do not cover the following types based on type expansion: userSelected.

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: type additional types) (Extension Type: Coding)

Is Modifier false

Summary false

452. ClaimResponse.processNote.type.value

Definition

Primitive value for code

Short Primitive value for code

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

454. ClaimResponse.processNote.text

Definition

The explanation or description associated with the processing.

Short Note explanatory text

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Required to provide human readable explanation.

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

456. ClaimResponse.processNote.language

Definition

A code to define the language used in the text of the note.

Short Language of the text

Comments

Only required if the language is different from the resource language.

Control 0..1

The codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages|4.3.0)

IETF language tag

Additional Bindings

Purpose

Is Modifier false

Must Support false

Summary false

Requirements

Note text may vary from the resource defined language.

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

458. ClaimResponse.communicationRequest

Definition

Request for additional supporting or authorizing information.

Short Request for additional information

Comments

For example: professional reports, documents, images, clinical resources, or accident reports.

Control 0..*

Type Reference(CommunicationRequest)

Is Modifier false

Must Support false

Summary false

Requirements

Need to communicate insurer request for additional information required to support the adjudication.

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

460. ClaimResponse.insurance

Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Short Patient insurance information

Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

At least one insurer is required for a claim to be a claim.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

462. ClaimResponse.insurance.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

464. ClaimResponse.insurance.extension

Definition

An Extension

Short Extension

Control 1..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.insurance.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

466. ClaimResponse.insurance.extension:relationship

Slice Name relationship

Definition

DSTU2: ClaimResponse.coverage.relationship (new:Coding)

Short DSTU2: Patient relationship to subscriber (new)

Comments

Element ClaimResponse.coverage.relationship has a context of ClaimResponse.insurance based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.coverage.relationship has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 1..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Patient relationship to subscriber (new)) (Extension Type: Coding)

Is Modifier false

Summary false

468. ClaimResponse.insurance.extension:preAuthRef

Slice Name preAuthRef

Definition

DSTU2: ClaimResponse.coverage.preAuthRef (new:string)

Short DSTU2: Pre-Authorization/Determination Reference (new)

Comments

Element ClaimResponse.coverage.preAuthRef has a context of ClaimResponse.insurance based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.coverage.preAuthRef has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..*
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Pre-Authorization/Determination Reference (new)) (Extension Type: string)

Is Modifier false

Summary false

470. ClaimResponse.insurance.extension:originalRuleset

Slice Name originalRuleset

Definition

DSTU2: ClaimResponse.coverage.originalRuleset (new:Coding)

Short DSTU2: Original version (new)

Comments

Element ClaimResponse.coverage.originalRuleset has a context of ClaimResponse.insurance based on following the parent source element upwards and mapping to ClaimResponse. Element ClaimResponse.coverage.originalRuleset has no mapping targets in FHIR R4B. Typically, this is because the element has been added (is a new element).

Control 0..1
This element is affected by the following invariants: ele-1

Type Extension(DSTU2: Original version (new)) (Extension Type: Coding)

Is Modifier false

Summary false

472. ClaimResponse.insurance.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

474. ClaimResponse.insurance.sequence

Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Short Insurance instance identifier

Control 1..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

To maintain order of the coverages.

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

476. ClaimResponse.insurance.focal

Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Short Coverage to be used for adjudication

Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Control 1..1

boolean

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

To identify which coverage in the list is being used to adjudicate this claim.

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

478. ClaimResponse.insurance.coverage

Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Short Insurance information

Control 1..1

Type Reference(Coverage)

Is Modifier false

Must Support false

Summary false

Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

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

480. ClaimResponse.insurance.coverage.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

482. ClaimResponse.insurance.coverage.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.insurance.coverage.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

484. ClaimResponse.insurance.coverage.extension:coverage

Slice Name coverage

Definition

DSTU2: ClaimResponse.coverage.coverage additional types from child elements (display, reference)

Short DSTU2: coverage additional types

Comments

Element ClaimResponse.coverage.coverage is mapped to FHIR R4B element ClaimResponse.insurance.coverage as SourceIsBroaderThanTarget. The mappings for ClaimResponse.coverage.coverage do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.coverage.coverage with unmapped reference targets: Coverage.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

486. ClaimResponse.insurance.coverage.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

488. ClaimResponse.insurance.coverage.type

Definition

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

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

490. ClaimResponse.insurance.coverage.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

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

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

492. ClaimResponse.insurance.coverage.display

Definition

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

Short Text alternative for the resource

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

494. ClaimResponse.insurance.businessArrangement

Definition

A business agreement number established between the provider and the insurer for special business processing purposes.

Short Additional provider contract number

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

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

496. ClaimResponse.insurance.claimResponse

Definition

The result of the adjudication of the line items for the Coverage specified in this insurance.

Short Adjudication results

Comments

Must not be specified when 'focal=true' for this insurance.

Control 0..1

Type Reference(ClaimResponse)

Is Modifier false

Must Support false

Summary false

Requirements

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

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

498. ClaimResponse.insurance.claimResponse.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

500. ClaimResponse.insurance.claimResponse.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.insurance.claimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

502. ClaimResponse.insurance.claimResponse.extension:claimResponse

Slice Name claimResponse

Definition

DSTU2: ClaimResponse.coverage.claimResponse additional types from child elements (display, reference)

Short DSTU2: claimResponse additional types

Comments

Element ClaimResponse.coverage.claimResponse is mapped to FHIR R4B element ClaimResponse.insurance.claimResponse as SourceIsBroaderThanTarget. The mappings for ClaimResponse.coverage.claimResponse do not cover the following types based on type expansion: display, reference. The standard extension alternate-reference has been mapped as the representation of FHIR DSTU2 element ClaimResponse.coverage.claimResponse with unmapped reference targets: ClaimResponse.

Control 0..1

Type Extension(Alternate Reference) (Extension Type: Reference(Resource))

Is Modifier false

Summary false

504. ClaimResponse.insurance.claimResponse.reference

Definition

Short Literal reference, Relative, internal or absolute URL

Comments

Control 0..1
This element is affected by the following invariants: ref-1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

506. ClaimResponse.insurance.claimResponse.type

Definition

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

Short Type the reference refers to (e.g. "Patient")

Comments

Control 0..1

Binding Unless not suitable, these codes SHALL be taken from ResourceType
(extensible to http://hl7.org/fhir/ValueSet/resource-types|4.3.0)

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

508. ClaimResponse.insurance.claimResponse.identifier

Definition

Short Logical reference, when literal reference is not known

Comments

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

Note This is a business identifier, not a resource identifier (see discussion)

Control 0..1

Is Modifier false

Summary true

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

510. ClaimResponse.insurance.claimResponse.display

Definition

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

Short Text alternative for the resource

Comments

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

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Summary true

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

512. ClaimResponse.error

Definition

Errors encountered during the processing of the adjudication.

Short Processing errors

Comments

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

Control 0..*

Is Modifier false

Must Support false

Summary false

Requirements

Need to communicate processing issues to the requestor.

Invariants ele-1: All FHIR elements must have a @value or children unless an empty Parameters resource (hasValue() or (children().count() > id.count()) or $this is Parameters)

514. ClaimResponse.error.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

516. ClaimResponse.error.extension

Definition

Short Additional content defined by implementations

Comments

Control 0..*

Is Modifier false

Summary false

Alternate Names extensions, user content

518. ClaimResponse.error.modifierExtension

Definition

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

Short Extensions that cannot be ignored even if unrecognized

Comments

Control 0..*

Is Modifier true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them

Summary true

Requirements

Alternate Names extensions, user content, modifiers

520. ClaimResponse.error.itemSequence

Definition

The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Short Item sequence number

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Provides references to the claim items.

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

522. ClaimResponse.error.detailSequence

Definition

The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Short Detail sequence number

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

Provides references to the claim details within the claim item.

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

524. ClaimResponse.error.subDetailSequence

Definition

The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Short Subdetail sequence number

Control 0..1

Is Modifier false

Primitive Value This primitive element may be present, or absent, or replaced by an extension

Must Support false

Summary false

Requirements

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

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

526. ClaimResponse.error.code

Definition

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

Short Error code detailing processing issues

Control 1..1

For example codes, see Adjudication Error Codes
(example to http://hl7.org/fhir/ValueSet/adjudication-error|4.3.0)

The adjudication error codes.

Is Modifier false

Must Support false

Summary false

Requirements

Required to convey processing errors.

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

528. ClaimResponse.error.code.id

Definition

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

Short Unique id for inter-element referencing

Control 0..1

Is Modifier false

XML Format In the XML format, this property is represented as an attribute.

Summary false

530. ClaimResponse.error.code.extension

Definition

An Extension

Short Extension

Control 0..*

Is Modifier false

Summary false

This element introduces a set of slices on ClaimResponse.error.code.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:

value @ url

532. ClaimResponse.error.code.extension:code

Slice Name code

Definition

DSTU2: ClaimResponse.error.code

Short DSTU2: code

Comments

Element ClaimResponse.error.code is mapped to FHIR R4B element ClaimResponse.error.code as SourceIsNarrowerThanTarget.

Control 1..1

Type Extension(DSTU2: code) (Extension Type: Coding)

Is Modifier false

Summary false

534. ClaimResponse.error.code.coding

Definition

A reference to a code defined by a terminology system.

Short Code defined by a terminology system

Comments

Control 0..*

Is Modifier false

Summary true

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

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

536. ClaimResponse.error.code.text

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Short Plain text representation of the concept

Comments

Very often the text is the same as a displayName of one of the codings.

Control 0..1