Extensions for Using Data Elements from FHIR R5 in FHIR R4
0.1.0 - STU
Extensions for Using Data Elements from FHIR R5 in FHIR R4
0.1.0 - STU
Extensions for Using Data Elements from FHIR R5 in FHIR R4 - Downloaded Version null See the Directory of published versions
| Page standards status: Trial-use | Maturity Level: 0 |
Definitions for the profile-ClaimResponse resource profile.
Guidance on how to interpret the contents of this table can be foundhere
| 0. ClaimResponse | |
| Definition | This resource provides the adjudication details from the processing of a Claim resource. |
| Short | Response to a claim predetermination or preauthorization |
| Control | 0..* |
| Is Modifier | false |
| Summary | false |
| Alternate Names | Remittance Advice |
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty())dom-6: A resource should have narrative for robust management ( text.`div`.exists())dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()) dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()) dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists()) |
| 2. ClaimResponse.implicitRules | |
| Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
| 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 |
| Type | uri |
| 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 |
| Summary | true |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 4. ClaimResponse.extension | |
| Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | ExtensionAdditional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| 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())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()) |
| Slicing | This element introduces a set of slices on ClaimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 6. ClaimResponse.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 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())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()) |
| 8. ClaimResponse.extension:decision | |
| Slice Name | decision |
| Definition | R5: |
| Short | R5: Result of the adjudication (new) |
| Comments | Element |
| Control | 0..1 This element is affected by the following invariants: ele-1 |
| Type | Extension(R5: Result of the adjudication (new)) (Extension Type: CodeableConcept) |
| 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())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()) |
| 10. ClaimResponse.extension:event | |
| Slice Name | event |
| Definition | R5: |
| Short | R5: Event information (new) |
| Comments | Element |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Type | Extension(R5: Event information (new)) (Complex Extension) |
| Is Modifier | 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()) |
| 12. ClaimResponse.extension:encounter | |
| Slice Name | encounter |
| Definition | R5: |
| Short | R5: Encounters associated with the listed treatments (new) |
| Comments | Element |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Type | Extension(R5: Encounters associated with the listed treatments (new)) (Extension Type: Reference(Cross-version Profile for R5.Encounter for use in FHIR R4, Encounter)) |
| 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())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()) |
| 14. ClaimResponse.extension:diagnosisRelatedGroup | |
| Slice Name | diagnosisRelatedGroup |
| Definition | R5: |
| Short | R5: Package billing code (new) |
| Comments | Element |
| Control | 0..1 This element is affected by the following invariants: ele-1 |
| Type | Extension(R5: Package billing code (new)) (Extension Type: CodeableConcept) |
| 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())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()) |
| 16. ClaimResponse.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| 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..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them |
| 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 |
| 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())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()) |
| 18. 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 |
| Binding | The codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)A code specifying the state of the resource instance. |
| Type | code |
| 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 |
| 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 20. ClaimResponse.type | |
| Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. |
| 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 |
| Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type|4.0.1 (extensible to http://hl7.org/fhir/ValueSet/claim-type|4.0.1)The type or discipline-style of the claim. |
| Type | CodeableConcept |
| Is Modifier | 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 22. ClaimResponse.use | |
| Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. |
| Short | claim | preauthorization | predetermination |
| Control | 1..1 |
| Binding | The codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)Claim, preauthorization, predetermination. |
| Type | code |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 24. ClaimResponse.patient | |
| Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought. |
| Short | The recipient of the products and services |
| Control | 1..1 |
| Type | Reference(Patient) |
| Is Modifier | 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 26. ClaimResponse.created | |
| Definition | The date this resource was created. |
| Short | Response creation date |
| Control | 1..1 |
| Type | dateTime |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 28. ClaimResponse.insurer | |
| Definition | The party responsible for authorization, adjudication and reimbursement. |
| Short | Party responsible for reimbursement |
| Control | 1..1 |
| Type | Reference(Organization) |
| Is Modifier | 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 30. 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 |
| Binding | The codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)The result of the claim processing. |
| Type | code |
| Is Modifier | false |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 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()))ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be foundhere
| 0. ClaimResponse | |
| 2. ClaimResponse.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 4. ClaimResponse.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 6. ClaimResponse.extension:decision | |
| Slice Name | decision |
| Definition | R5: |
| Short | R5: Result of the adjudication (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Result of the adjudication (new)) (Extension Type: CodeableConcept) |
| 8. ClaimResponse.extension:event | |
| Slice Name | event |
| Definition | R5: |
| Short | R5: Event information (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Event information (new)) (Complex Extension) |
| 10. ClaimResponse.extension:encounter | |
| Slice Name | encounter |
| Definition | R5: |
| Short | R5: Encounters associated with the listed treatments (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Encounters associated with the listed treatments (new)) (Extension Type: Reference(Cross-version Profile for R5.Encounter for use in FHIR R4, Encounter)) |
| 12. ClaimResponse.extension:diagnosisRelatedGroup | |
| Slice Name | diagnosisRelatedGroup |
| Definition | R5: |
| Short | R5: Package billing code (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Package billing code (new)) (Extension Type: CodeableConcept) |
| 14. ClaimResponse.item | |
| 16. ClaimResponse.item.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 18. ClaimResponse.item.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 20. ClaimResponse.item.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 22. ClaimResponse.item.adjudication | |
| 24. ClaimResponse.item.adjudication.value | |
| 26. ClaimResponse.item.adjudication.value.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.item.adjudication.value.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 28. ClaimResponse.item.adjudication.value.extension:quantity | |
| Slice Name | quantity |
| Definition | R5: |
| Short | R5: quantity additional types |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: quantity additional types) (Extension Type: Quantity) |
| 30. ClaimResponse.item.detail | |
| 32. ClaimResponse.item.detail.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.item.detail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 34. ClaimResponse.item.detail.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 36. ClaimResponse.item.detail.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Detail level adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 38. ClaimResponse.item.detail.subDetail | |
| 40. ClaimResponse.item.detail.subDetail.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.item.detail.subDetail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 42. ClaimResponse.item.detail.subDetail.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 44. ClaimResponse.item.detail.subDetail.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Subdetail level adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 46. ClaimResponse.addItem | |
| 48. ClaimResponse.addItem.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 50. ClaimResponse.addItem.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 52. ClaimResponse.addItem.extension:revenue | |
| Slice Name | revenue |
| Definition | R5: |
| Short | R5: Revenue or cost center code (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) |
| 54. ClaimResponse.addItem.extension:productOrServiceEnd | |
| Slice Name | productOrServiceEnd |
| Definition | R5: |
| Short | R5: End of a range of codes (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) |
| 56. ClaimResponse.addItem.extension:request | |
| Slice Name | request |
| Definition | R5: |
| Short | R5: Request or Referral for Service (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Request or Referral for Service (new)) (Extension Type: Reference(Cross-version Profile for R5.DeviceRequest for use in FHIR R4, DeviceRequest, Cross-version Profile for R5.MedicationRequest for use in FHIR R4, MedicationRequest, Cross-version Profile for R5.NutritionOrder for use in FHIR R4, NutritionOrder, Cross-version Profile for R5.ServiceRequest for use in FHIR R4, ServiceRequest, Cross-version Profile for R5.SupplyRequest for use in FHIR R4, SupplyRequest, Cross-version Profile for R5.VisionPrescription for use in FHIR R4, VisionPrescription)) |
| 58. ClaimResponse.addItem.extension:tax | |
| Slice Name | tax |
| Definition | R5: |
| Short | R5: Total tax (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) |
| 60. ClaimResponse.addItem.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Added items adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 62. ClaimResponse.addItem.bodySite | |
| 64. ClaimResponse.addItem.bodySite.extension | |
| Control | 1..* |
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.bodySite.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 66. ClaimResponse.addItem.bodySite.extension:site | |
| Slice Name | site |
| Definition | R5: |
| Short | R5: Location (new) |
| Comments | Element |
| Control | 1..* |
| Type | Extension(R5: Location (new)) (Complex Extension) |
| 68. ClaimResponse.addItem.bodySite.extension:subSite | |
| Slice Name | subSite |
| Definition | R5: |
| Short | R5: Sub-location (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Sub-location (new)) (Extension Type: CodeableConcept) |
| 70. ClaimResponse.addItem.detail | |
| 72. ClaimResponse.addItem.detail.extension | |
| Control | 0..* |
| Slicing | 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: |
| 74. ClaimResponse.addItem.detail.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 76. ClaimResponse.addItem.detail.extension:revenue | |
| Slice Name | revenue |
| Definition | R5: |
| Short | R5: Revenue or cost center code (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) |
| 78. ClaimResponse.addItem.detail.extension:productOrServiceEnd | |
| Slice Name | productOrServiceEnd |
| Definition | R5: |
| Short | R5: End of a range of codes (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) |
| 80. ClaimResponse.addItem.detail.extension:tax | |
| Slice Name | tax |
| Definition | R5: |
| Short | R5: Total tax (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) |
| 82. ClaimResponse.addItem.detail.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Added items detail level adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 84. ClaimResponse.addItem.detail.subDetail | |
| 86. ClaimResponse.addItem.detail.subDetail.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.detail.subDetail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 88. ClaimResponse.addItem.detail.subDetail.extension:traceNumber | |
| Slice Name | traceNumber |
| Definition | R5: |
| Short | R5: Number for tracking (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) |
| 90. ClaimResponse.addItem.detail.subDetail.extension:revenue | |
| Slice Name | revenue |
| Definition | R5: |
| Short | R5: Revenue or cost center code (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) |
| 92. ClaimResponse.addItem.detail.subDetail.extension:productOrServiceEnd | |
| Slice Name | productOrServiceEnd |
| Definition | R5: |
| Short | R5: End of a range of codes (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) |
| 94. ClaimResponse.addItem.detail.subDetail.extension:tax | |
| Slice Name | tax |
| Definition | R5: |
| Short | R5: Total tax (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) |
| 96. ClaimResponse.addItem.detail.subDetail.extension:reviewOutcome | |
| Slice Name | reviewOutcome |
| Definition | R5: |
| Short | R5: Added items subdetail level adjudication results (new) |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) |
| 98. ClaimResponse.processNote | |
| 100. ClaimResponse.processNote.type | |
| 102. ClaimResponse.processNote.type.extension | |
| Control | 0..* |
| Slicing | 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: |
| 104. ClaimResponse.processNote.type.extension:type | |
| Slice Name | type |
| Definition | R5: |
| Short | R5: Note purpose additional types |
| Comments | Element |
| Control | 0..1 |
| Type | Extension(R5: Note purpose additional types) (Extension Type: CodeableConcept) |
| 106. ClaimResponse.error | |
| 108. ClaimResponse.error.extension | |
| Control | 0..* |
| Slicing | This element introduces a set of slices on ClaimResponse.error.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 110. ClaimResponse.error.extension:expression | |
| Slice Name | expression |
| Definition | R5: |
| Short | R5: FHIRPath of element(s) related to issue (new) |
| Comments | Element |
| Control | 0..* |
| Type | Extension(R5: FHIRPath of element(s) related to issue (new)) (Extension Type: string) |
Guidance on how to interpret the contents of this table can be foundhere
| 0. ClaimResponse | |||||
| Definition | This resource provides the adjudication details from the processing of a Claim resource. | ||||
| Short | Response to a claim predetermination or preauthorization | ||||
| Control | 0..* | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | Remittance Advice | ||||
| Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource ( contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated ( contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())dom-5: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty())dom-6: A resource should have narrative for robust management ( text.`div`.exists()) | ||||
| 2. ClaimResponse.id | |||||
| Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
| Short | Logical id of this artifact | ||||
| Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
| Control | 0..1 | ||||
| Type | id | ||||
| Is Modifier | 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 | ||||
| Type | Meta | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 6. ClaimResponse.implicitRules | |||||
| Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
| 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 | ||||
| Type | uri | ||||
| 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 | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 8. ClaimResponse.language | |||||
| Definition | The base language in which the resource is written. | ||||
| 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 | ||||
| Binding | The codes SHOULD be taken from CommonLanguages  (preferred to http://hl7.org/fhir/ValueSet/languages|4.0.1)A human language.
| ||||
| Type | code | ||||
| 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())) | ||||
| 10. ClaimResponse.text | |||||
| Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
| 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 | ||||
| Type | Narrative | ||||
| Is Modifier | 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())) | ||||
| 12. ClaimResponse.contained | |||||
| Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
| 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..* | ||||
| Type | Resource | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | inline resources, anonymous resources, contained resources | ||||
| 14. ClaimResponse.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 16. ClaimResponse.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 18. ClaimResponse.extension:decision | |||||
| Slice Name | decision | ||||
| Definition | R5: | ||||
| Short | R5: Result of the adjudication (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Result of the adjudication (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 20. ClaimResponse.extension:event | |||||
| Slice Name | event | ||||
| Definition | R5: | ||||
| Short | R5: Event information (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Event information (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 22. ClaimResponse.extension:encounter | |||||
| Slice Name | encounter | ||||
| Definition | R5: | ||||
| Short | R5: Encounters associated with the listed treatments (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Encounters associated with the listed treatments (new)) (Extension Type: Reference(Cross-version Profile for R5.Encounter for use in FHIR R4, Encounter)) | ||||
| 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()) | ||||
| 24. ClaimResponse.extension:diagnosisRelatedGroup | |||||
| Slice Name | diagnosisRelatedGroup | ||||
| Definition | R5: | ||||
| Short | R5: Package billing code (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Package billing code (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 26. 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..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
| 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 | ||||
| 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()) | ||||
| 28. 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..* | ||||
| Type | Identifier | ||||
| Is Modifier | 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())) | ||||
| 30. 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 | ||||
| Binding | The codes SHALL be taken from FinancialResourceStatusCodes (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)A code specifying the state of the resource instance. | ||||
| Type | code | ||||
| 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 | ||||
| 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())) | ||||
| 32. 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 | ||||
| Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes (extensible to http://hl7.org/fhir/ValueSet/claim-type|4.0.1)The type or discipline-style of the claim. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 34. 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 | ||||
| Binding | For example codes, see ExampleClaimSubTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1)A more granular claim typecode. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 36. 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 | ||||
| Binding | The codes SHALL be taken from Use (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)Claim, preauthorization, predetermination. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 38. 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 | ||||
| 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())) | ||||
| 40. ClaimResponse.created | |||||
| Definition | The date this resource was created. | ||||
| Short | Response creation date | ||||
| Control | 1..1 | ||||
| Type | dateTime | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 42. 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 | ||||
| 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())) | ||||
| 44. 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 | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 46. ClaimResponse.request | |||||
| Definition | Original request resource reference. | ||||
| Short | Id of resource triggering adjudication | ||||
| Control | 0..1 | ||||
| Type | Reference(Claim) | ||||
| Is Modifier | false | ||||
| Summary | true | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 48. 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 | ||||
| Binding | The codes SHALL be taken from ClaimProcessingCodes (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)The result of the claim processing. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 50. ClaimResponse.disposition | |||||
| Definition | A human readable description of the status of the adjudication. | ||||
| Short | Disposition Message | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 52. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 54. ClaimResponse.preAuthPeriod | |||||
| Definition | The time frame during which this authorization is effective. | ||||
| Short | Preauthorization reference effective period | ||||
| Control | 0..1 | ||||
| Type | Period | ||||
| Is Modifier | 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())) | ||||
| 56. ClaimResponse.payeeType | |||||
| Definition | Type of Party to be reimbursed: subscriber, provider, other. | ||||
| Short | Party to be paid any benefits payable | ||||
| Control | 0..1 | ||||
| Binding | For example codes, see Claim Payee Type Codes (example to http://hl7.org/fhir/ValueSet/payeetype|4.0.1)A code for the party to be reimbursed. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 58. 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..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | The adjudication for items provided on the claim. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 60. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 62. ClaimResponse.item.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 64. ClaimResponse.item.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 66. ClaimResponse.item.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 68. 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 | 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..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 70. ClaimResponse.item.itemSequence | |||||
| Definition | A number to uniquely reference the claim item entries. | ||||
| Short | Claim item instance identifier | ||||
| Control | 1..1 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 72. ClaimResponse.item.noteNumber | |||||
| Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
| Short | Applicable note numbers | ||||
| Control | 0..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 74. 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..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 76. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 78. ClaimResponse.item.adjudication.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 | 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..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| 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()) | ||||
| 80. ClaimResponse.item.adjudication.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 82. 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 | ||||
| Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication|4.0.1)The adjudication codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 84. 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 | ||||
| Binding | For example codes, see AdjudicationReasonCodes (example to http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1)The adjudication reason codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 86. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 88. 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 | ||||
| Type | decimal | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 90. ClaimResponse.item.adjudication.value.id | |||||
| Definition | unique id for the element within a resource (for internal references) | ||||
| Short | xml:id (or equivalent in JSON) | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 92. ClaimResponse.item.adjudication.value.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.item.adjudication.value.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 94. ClaimResponse.item.adjudication.value.extension:quantity | |||||
| Slice Name | quantity | ||||
| Definition | R5: | ||||
| Short | R5: quantity additional types | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: quantity additional types) (Extension Type: Quantity) | ||||
| 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()) | ||||
| 96. ClaimResponse.item.adjudication.value.value | |||||
| Definition | The actual value | ||||
| Short | Primitive value for decimal | ||||
| Control | 0..1 | ||||
| Type | decimal | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 98. 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..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | The adjudication for details provided on the claim. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 100. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 102. ClaimResponse.item.detail.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.item.detail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 104. ClaimResponse.item.detail.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 106. ClaimResponse.item.detail.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Detail level adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 108. ClaimResponse.item.detail.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 110. ClaimResponse.item.detail.detailSequence | |||||
| Definition | A number to uniquely reference the claim detail entry. | ||||
| Short | Claim detail instance identifier | ||||
| Control | 1..1 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 112. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 114. ClaimResponse.item.detail.adjudication | |||||
| Definition | The adjudication results. | ||||
| Short | Detail level adjudication details | ||||
| Control | 1..* | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 116. ClaimResponse.item.detail.subDetail | |||||
| Definition | A sub-detail adjudication of a simple product or service. | ||||
| Short | Adjudication for claim sub-details | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 118. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 120. ClaimResponse.item.detail.subDetail.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.item.detail.subDetail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 122. ClaimResponse.item.detail.subDetail.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 124. ClaimResponse.item.detail.subDetail.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Subdetail level adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 126. ClaimResponse.item.detail.subDetail.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 128. 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 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 130. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 132. ClaimResponse.item.detail.subDetail.adjudication | |||||
| Definition | The adjudication results. | ||||
| Short | Subdetail level adjudication details | ||||
| Control | 0..* | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 134. ClaimResponse.addItem | |||||
| Definition | The first-tier service adjudications for payor added product or service lines. | ||||
| Short | Insurer added line items | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 136. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 138. ClaimResponse.addItem.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 140. ClaimResponse.addItem.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 142. ClaimResponse.addItem.extension:revenue | |||||
| Slice Name | revenue | ||||
| Definition | R5: | ||||
| Short | R5: Revenue or cost center code (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 144. ClaimResponse.addItem.extension:productOrServiceEnd | |||||
| Slice Name | productOrServiceEnd | ||||
| Definition | R5: | ||||
| Short | R5: End of a range of codes (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 146. ClaimResponse.addItem.extension:request | |||||
| Slice Name | request | ||||
| Definition | R5: | ||||
| Short | R5: Request or Referral for Service (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Request or Referral for Service (new)) (Extension Type: Reference(Cross-version Profile for R5.DeviceRequest for use in FHIR R4, DeviceRequest, Cross-version Profile for R5.MedicationRequest for use in FHIR R4, MedicationRequest, Cross-version Profile for R5.NutritionOrder for use in FHIR R4, NutritionOrder, Cross-version Profile for R5.ServiceRequest for use in FHIR R4, ServiceRequest, Cross-version Profile for R5.SupplyRequest for use in FHIR R4, SupplyRequest, Cross-version Profile for R5.VisionPrescription for use in FHIR R4, VisionPrescription)) | ||||
| 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()) | ||||
| 148. ClaimResponse.addItem.extension:tax | |||||
| Slice Name | tax | ||||
| Definition | R5: | ||||
| Short | R5: Total tax (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) | ||||
| 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()) | ||||
| 150. ClaimResponse.addItem.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Added items adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 152. ClaimResponse.addItem.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 154. ClaimResponse.addItem.itemSequence | |||||
| Definition | Claim items which this service line is intended to replace. | ||||
| Short | Item sequence number | ||||
| Control | 0..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 156. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 158. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 160. 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 | ||||
| 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())) | ||||
| 162. 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 | ||||
| Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls|4.0.1)Allowable service and product codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 164. 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..* | ||||
| Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1)Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 166. 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..* | ||||
| Binding | For example codes, see ExampleProgramReasonCodes (example to http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1)Program specific reason codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 168. 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 | ||||
| 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())) | ||||
| 170. ClaimResponse.addItem.location[x] | |||||
| Definition | Where the product or service was provided. | ||||
| Short | Place of service or where product was supplied | ||||
| Control | 0..1 | ||||
| Binding | For example codes, see ExampleServicePlaceCodes (example to http://hl7.org/fhir/ValueSet/service-place|4.0.1)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 | ||||
| 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())) | ||||
| 172. 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 | ||||
| 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())) | ||||
| 174. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 176. 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 | ||||
| Type | decimal | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 178. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 180. 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 | ||||
| Binding | For example codes, see OralSiteCodes (example to http://hl7.org/fhir/ValueSet/tooth|4.0.1)The code for the teeth, quadrant, sextant and arch. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 182. ClaimResponse.addItem.bodySite.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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 184. ClaimResponse.addItem.bodySite.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 1..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.bodySite.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 186. ClaimResponse.addItem.bodySite.extension:site | |||||
| Slice Name | site | ||||
| Definition | R5: | ||||
| Short | R5: Location (new) | ||||
| Comments | Element | ||||
| Control | 1..* | ||||
| Type | Extension(R5: Location (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 188. ClaimResponse.addItem.bodySite.extension:subSite | |||||
| Slice Name | subSite | ||||
| Definition | R5: | ||||
| Short | R5: Sub-location (new) | ||||
| Comments | Element | ||||
| Control | 0..* | ||||
| Type | Extension(R5: Sub-location (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 190. ClaimResponse.addItem.bodySite.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..* | ||||
| Type | Coding | ||||
| 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())) | ||||
| 192. ClaimResponse.addItem.bodySite.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 | ||||
| Type | string | ||||
| 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())) | ||||
| 194. 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..* | ||||
| Binding | For example codes, see SurfaceCodes (example to http://hl7.org/fhir/ValueSet/surface|4.0.1)The code for the tooth surface and surface combinations. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 196. ClaimResponse.addItem.noteNumber | |||||
| Definition | The numbers associated with notes below which apply to the adjudication of this item. | ||||
| Short | Applicable note numbers | ||||
| Control | 0..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 198. ClaimResponse.addItem.adjudication | |||||
| Definition | The adjudication results. | ||||
| Short | Added items adjudication | ||||
| Control | 1..* | ||||
| Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 200. ClaimResponse.addItem.detail | |||||
| Definition | The second-tier service adjudications for payor added services. | ||||
| Short | Insurer added line details | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 202. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 204. ClaimResponse.addItem.detail.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | 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: | ||||
| 206. ClaimResponse.addItem.detail.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 208. ClaimResponse.addItem.detail.extension:revenue | |||||
| Slice Name | revenue | ||||
| Definition | R5: | ||||
| Short | R5: Revenue or cost center code (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 210. ClaimResponse.addItem.detail.extension:productOrServiceEnd | |||||
| Slice Name | productOrServiceEnd | ||||
| Definition | R5: | ||||
| Short | R5: End of a range of codes (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 212. ClaimResponse.addItem.detail.extension:tax | |||||
| Slice Name | tax | ||||
| Definition | R5: | ||||
| Short | R5: Total tax (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) | ||||
| 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()) | ||||
| 214. ClaimResponse.addItem.detail.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Added items detail level adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 216. ClaimResponse.addItem.detail.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 218. 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 | 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 | ||||
| Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls|4.0.1)Allowable service and product codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 220. 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..* | ||||
| Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1)Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 222. 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 | ||||
| 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())) | ||||
| 224. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 226. ClaimResponse.addItem.detail.factor | |||||
| Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
| 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 | ||||
| Type | decimal | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 228. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 230. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 232. ClaimResponse.addItem.detail.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 | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 234. ClaimResponse.addItem.detail.subDetail | |||||
| Definition | The third-tier service adjudications for payor added services. | ||||
| Short | Insurer added line items | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 236. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 238. ClaimResponse.addItem.detail.subDetail.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.addItem.detail.subDetail.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 240. ClaimResponse.addItem.detail.subDetail.extension:traceNumber | |||||
| Slice Name | traceNumber | ||||
| Definition | R5: | ||||
| Short | R5: Number for tracking (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Number for tracking (new)) (Extension Type: Identifier) | ||||
| 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()) | ||||
| 242. ClaimResponse.addItem.detail.subDetail.extension:revenue | |||||
| Slice Name | revenue | ||||
| Definition | R5: | ||||
| Short | R5: Revenue or cost center code (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Revenue or cost center code (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 244. ClaimResponse.addItem.detail.subDetail.extension:productOrServiceEnd | |||||
| Slice Name | productOrServiceEnd | ||||
| Definition | R5: | ||||
| Short | R5: End of a range of codes (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: End of a range of codes (new)) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 246. ClaimResponse.addItem.detail.subDetail.extension:tax | |||||
| Slice Name | tax | ||||
| Definition | R5: | ||||
| Short | R5: Total tax (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Total tax (new)) (Extension Type: Money) | ||||
| 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()) | ||||
| 248. ClaimResponse.addItem.detail.subDetail.extension:reviewOutcome | |||||
| Slice Name | reviewOutcome | ||||
| Definition | R5: | ||||
| Short | R5: Added items subdetail level adjudication results (new) | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Adjudication results (new)) (Complex Extension) | ||||
| Is Modifier | 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()) | ||||
| 250. ClaimResponse.addItem.detail.subDetail.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 252. 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 | 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 | ||||
| Binding | For example codes, see USCLSCodes (example to http://hl7.org/fhir/ValueSet/service-uscls|4.0.1)Allowable service and product codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 254. 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..* | ||||
| Binding | For example codes, see ModifierTypeCodes (example to http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1)Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 256. 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 | ||||
| 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())) | ||||
| 258. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 260. ClaimResponse.addItem.detail.subDetail.factor | |||||
| Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. | ||||
| 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 | ||||
| Type | decimal | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 262. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 264. 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..* | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 266. 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 | ||||
| Summary | false | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 268. 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 | ||||
| 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())) | ||||
| 270. ClaimResponse.total | |||||
| Definition | Categorized monetary totals for the adjudication. | ||||
| Short | Adjudication totals | ||||
| Comments | Totals for amounts submitted, co-pays, benefits payable etc. | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 272. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 274. ClaimResponse.total.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| 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()) | ||||
| 276. ClaimResponse.total.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 278. 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 | ||||
| Binding | For example codes, see AdjudicationValueCodes (example to http://hl7.org/fhir/ValueSet/adjudication|4.0.1)The adjudication codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 280. ClaimResponse.total.amount | |||||
| Definition | Monetary total amount associated with the category. | ||||
| Short | Financial total for the category | ||||
| Control | 1..1 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 282. ClaimResponse.payment | |||||
| Definition | Payment details for the adjudication of the claim. | ||||
| Short | Payment Details | ||||
| Control | 0..1 | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 284. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 286. ClaimResponse.payment.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| 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()) | ||||
| 288. ClaimResponse.payment.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 290. ClaimResponse.payment.type | |||||
| Definition | Whether this represents partial or complete payment of the benefits payable. | ||||
| Short | Partial or complete payment | ||||
| Control | 1..1 | ||||
| Binding | For example codes, see ExamplePaymentTypeCodes (example to http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1)The type (partial, complete) of the payment. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 292. 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 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 294. ClaimResponse.payment.adjustmentReason | |||||
| Definition | Reason for the payment adjustment. | ||||
| Short | Explanation for the adjustment | ||||
| Control | 0..1 | ||||
| Binding | For example codes, see PaymentAdjustmentReasonCodes (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1)Payment Adjustment reason codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 296. 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 | ||||
| Type | date | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 298. ClaimResponse.payment.amount | |||||
| Definition | Benefits payable less any payment adjustment. | ||||
| Short | Payable amount after adjustment | ||||
| Control | 1..1 | ||||
| Type | Money | ||||
| Is Modifier | 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())) | ||||
| 300. 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 | ||||
| Type | Identifier | ||||
| Is Modifier | 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())) | ||||
| 302. 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 | ||||
| Binding | For example codes, see Funds Reservation Codes (example to http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1)For whom funds are to be reserved: (Patient, Provider, None). | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 304. 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 | ||||
| Binding | For example codes, see Form Codes (example to http://hl7.org/fhir/ValueSet/forms|4.0.1)The forms codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 306. 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 | ||||
| Type | Attachment | ||||
| Is Modifier | 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())) | ||||
| 308. ClaimResponse.processNote | |||||
| Definition | A note that describes or explains adjudication results in a human readable form. | ||||
| Short | Note concerning adjudication | ||||
| Control | 0..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 310. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 312. ClaimResponse.processNote.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| 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()) | ||||
| 314. ClaimResponse.processNote.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 316. ClaimResponse.processNote.number | |||||
| Definition | A number to uniquely identify a note entry. | ||||
| Short | Note instance identifier | ||||
| Control | 0..1 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 318. ClaimResponse.processNote.type | |||||
| Definition | The business purpose of the note text. | ||||
| Short | display | print | printoper | ||||
| Control | 0..1 | ||||
| Binding | The codes SHALL be taken from NoteType (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)The presentation types of notes. | ||||
| Type | code | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 320. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 322. ClaimResponse.processNote.type.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | 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: | ||||
| 324. ClaimResponse.processNote.type.extension:type | |||||
| Slice Name | type | ||||
| Definition | R5: | ||||
| Short | R5: Note purpose additional types | ||||
| Comments | Element | ||||
| Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: Note purpose additional types) (Extension Type: CodeableConcept) | ||||
| 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()) | ||||
| 326. ClaimResponse.processNote.type.value | |||||
| Definition | Primitive value for code | ||||
| Short | Primitive value for code | ||||
| Control | 0..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 328. ClaimResponse.processNote.text | |||||
| Definition | The explanation or description associated with the processing. | ||||
| Short | Note explanatory text | ||||
| Control | 1..1 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 330. 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 | ||||
| Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages|4.0.1)A human language.
| ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
| 332. 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 | ||||
| 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())) | ||||
| 334. 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..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | 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 (hasValue() or (children().count() > id.count())) | ||||
| 336. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 338. ClaimResponse.insurance.extension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
| Short | Additional content defined by implementations | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Alternate Names | extensions, user content | ||||
| 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()) | ||||
| 340. ClaimResponse.insurance.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 342. 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 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 344. 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 | ||||
| Type | boolean | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 346. 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 | ||||
| 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())) | ||||
| 348. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 350. 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 | ||||
| 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())) | ||||
| 352. 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..* | ||||
| Type | BackboneElement | ||||
| Is Modifier | false | ||||
| Summary | false | ||||
| Requirements | Need to communicate processing issues to the requestor. | ||||
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) | ||||
| 354. 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 | ||||
| Type | string | ||||
| Is Modifier | false | ||||
| XML Format | In the XML format, this property is represented as an attribute. | ||||
| Summary | false | ||||
| 356. ClaimResponse.error.extension | |||||
| Definition | An Extension | ||||
| Short | Extension | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| 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()) | ||||
| Slicing | This element introduces a set of slices on ClaimResponse.error.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: | ||||
| 358. ClaimResponse.error.extension:expression | |||||
| Slice Name | expression | ||||
| Definition | R5: | ||||
| Short | R5: FHIRPath of element(s) related to issue (new) | ||||
| Comments | Element | ||||
| Control | 0..* This element is affected by the following invariants: ele-1 | ||||
| Type | Extension(R5: FHIRPath of element(s) related to issue (new)) (Extension Type: string) | ||||
| 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()) | ||||
| 360. ClaimResponse.error.modifierExtension | |||||
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
| Short | Extensions that cannot be ignored even if unrecognized | ||||
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
| Control | 0..* | ||||
| Type | Extension | ||||
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
| Summary | true | ||||
| 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, modifiers | ||||
| 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()) | ||||
| 362. 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 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 364. 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 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 366. 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 | ||||
| Type | positiveInt | ||||
| Is Modifier | false | ||||
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
| 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())) | ||||
| 368. 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 | ||||
| Binding | For example codes, see Adjudication Error Codes (example to http://hl7.org/fhir/ValueSet/adjudication-error|4.0.1)The adjudication error codes. | ||||
| Type | CodeableConcept | ||||
| Is Modifier | 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())) | ||||
IG © 2025+ FHIR Infrastructure. Package hl7.fhir.uv.xver-r5.r4#0.1.0 based on FHIR 4.0.1. Generated 2026-03-20
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