R4 Draft for Comment
FinancialThis page is part of the FHIR Specification (v3.2.0: R4 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
| Financial Management Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Patient, Practitioner |
StructureDefinition for claimresponse
{
"resourceType": "StructureDefinition",
"id": "ClaimResponse",
"meta": {
"lastUpdated": "2017-12-20T15:52:34.818+11:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
},
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
}
],
"url": "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
"name": "ClaimResponse",
"status": "draft",
"date": "2017-12-20T15:52:34+11:00",
"publisher": "Health Level Seven International (Financial Management)",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org/Special/committees/fm/index.cfm"
}
]
}
],
"description": "This resource provides the adjudication details from the processing of a Claim resource.",
"fhirVersion": "3.2.0",
"mapping": [
{
"identity": "workflow",
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
}
],
"kind": "resource",
"abstract": false,
"type": "ClaimResponse",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "ClaimResponse",
"path": "ClaimResponse",
"short": "Remittance resource",
"definition": "This resource provides the adjudication details from the processing of a Claim resource.",
"alias": [
"Remittance Advice"
],
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)",
"source": "DomainResource"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "DomainResource"
},
{
"key": "dom-3",
"severity": "error",
"human": "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",
"expression": "contained.all(('#'+id in %resource.descendants().reference) or descendants().where(reference = '#').exists())",
"xpath": "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::reference[@value='#'])]))",
"source": "DomainResource"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "ClaimResponse.id",
"path": "ClaimResponse.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "ClaimResponse.meta",
"path": "ClaimResponse.meta",
"short": "Metadata about the resource",
"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.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "ClaimResponse.implicitRules",
"path": "ClaimResponse.implicitRules",
"short": "A set of rules under which this content was created",
"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.",
"comment": "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. \n\nThis element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "ClaimResponse.language",
"path": "ClaimResponse.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comment": "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).",
"min": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ClaimResponse.text",
"path": "ClaimResponse.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may 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.",
"comment": "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 in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "ClaimResponse.contained",
"path": "ClaimResponse.contained",
"short": "Contained, inline Resources",
"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.",
"comment": "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.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.extension",
"path": "ClaimResponse.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.modifierExtension",
"path": "ClaimResponse.modifierExtension",
"short": "Extensions that cannot be ignored",
"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. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.identifier",
"path": "ClaimResponse.identifier",
"short": "Response number",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ClaimResponse.status",
"path": "ClaimResponse.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code cancelled and entered-in-error that mark the response as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimResponseStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ClaimResponse.patient",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "who.focus"
}
],
"path": "ClaimResponse.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
]
},
{
"id": "ClaimResponse.created",
"path": "ClaimResponse.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence[x]"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ClaimResponse.insurer",
"path": "ClaimResponse.insurer",
"short": "Insurance issuing organization",
"definition": "The Insurer who produced this adjudicated response.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer"
}
]
},
{
"id": "ClaimResponse.requestProvider",
"path": "ClaimResponse.requestProvider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ClaimResponse.requestOrganization",
"path": "ClaimResponse.requestOrganization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ClaimResponse.request",
"path": "ClaimResponse.request",
"short": "Id of resource triggering adjudication",
"definition": "Original request resource referrence.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.basedOn"
},
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ClaimResponse.outcome",
"path": "ClaimResponse.outcome",
"short": "complete | error | partial",
"definition": "Transaction: error, complete, partial processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
}
],
"strength": "required",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "ClaimResponse.disposition",
"path": "ClaimResponse.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
},
{
"id": "ClaimResponse.payeeType",
"path": "ClaimResponse.payeeType",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "ClaimResponse.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "ClaimResponse.item",
"short": "Line items",
"definition": "The first tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.item.id",
"path": "ClaimResponse.item.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.extension",
"path": "ClaimResponse.item.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.modifierExtension",
"path": "ClaimResponse.item.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.item.itemSequence",
"path": "ClaimResponse.item.itemSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.noteNumber",
"path": "ClaimResponse.item.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.adjudication",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
}
],
"path": "ClaimResponse.item.adjudication",
"short": "Adjudication details",
"definition": "The adjudication results.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.item.adjudication.id",
"path": "ClaimResponse.item.adjudication.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.adjudication.extension",
"path": "ClaimResponse.item.adjudication.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.adjudication.modifierExtension",
"path": "ClaimResponse.item.adjudication.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.item.adjudication.category",
"path": "ClaimResponse.item.adjudication.category",
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"definition": "Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
}
],
"strength": "example",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
}
},
{
"id": "ClaimResponse.item.adjudication.reason",
"path": "ClaimResponse.item.adjudication.reason",
"short": "Explanation of Adjudication outcome",
"definition": "Adjudication reason such as limit reached.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
}
],
"strength": "example",
"description": "The adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
}
},
{
"id": "ClaimResponse.item.adjudication.amount",
"path": "ClaimResponse.item.adjudication.amount",
"short": "Monetary amount",
"definition": "Monetary amount associated with the code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.item.adjudication.value",
"path": "ClaimResponse.item.adjudication.value",
"short": "Non-monetary value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ClaimResponse.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
}
],
"path": "ClaimResponse.item.detail",
"short": "Detail line items",
"definition": "The second tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.item.detail.id",
"path": "ClaimResponse.item.detail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.detail.extension",
"path": "ClaimResponse.item.detail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.detail.modifierExtension",
"path": "ClaimResponse.item.detail.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.item.detail.detailSequence",
"path": "ClaimResponse.item.detail.detailSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.noteNumber",
"path": "ClaimResponse.item.detail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.adjudication",
"path": "ClaimResponse.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "ClaimResponse.item.detail.subDetail",
"short": "Subdetail line items",
"definition": "The third tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.id",
"path": "ClaimResponse.item.detail.subDetail.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.extension",
"path": "ClaimResponse.item.detail.subDetail.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.modifierExtension",
"path": "ClaimResponse.item.detail.subDetail.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"path": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"short": "Subdetail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.addItem",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
}
],
"path": "ClaimResponse.addItem",
"short": "Insurer added line items",
"definition": "The first tier service adjudications for payor added services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.addItem.id",
"path": "ClaimResponse.addItem.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.addItem.extension",
"path": "ClaimResponse.addItem.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.addItem.modifierExtension",
"path": "ClaimResponse.addItem.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.addItem.itemSequence",
"path": "ClaimResponse.addItem.itemSequence",
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.detailSequence",
"path": "ClaimResponse.addItem.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.subdetailSequence",
"path": "ClaimResponse.addItem.subdetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.service",
"path": "ClaimResponse.addItem.service",
"short": "Group, Service or Product",
"definition": "A code to indicate the Professional Service or Product supplied.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ClaimResponse.addItem.modifier",
"path": "ClaimResponse.addItem.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"mapping": [
{
"identity": "rim",
"map": "24.C, 24.D mods"
}
]
},
{
"id": "ClaimResponse.addItem.fee",
"path": "ClaimResponse.addItem.fee",
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product..",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.addItem.noteNumber",
"path": "ClaimResponse.addItem.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.adjudication",
"path": "ClaimResponse.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.error",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
}
],
"path": "ClaimResponse.error",
"short": "Processing errors",
"definition": "Mutually exclusive with Services Provided (Item).",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.error.id",
"path": "ClaimResponse.error.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.error.extension",
"path": "ClaimResponse.error.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.error.modifierExtension",
"path": "ClaimResponse.error.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.error.itemSequence",
"path": "ClaimResponse.error.itemSequence",
"short": "Item sequence number",
"definition": "The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.detailSequence",
"path": "ClaimResponse.error.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.subDetailSequence",
"path": "ClaimResponse.error.subDetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.code",
"path": "ClaimResponse.error.code",
"short": "Error code detailing processing issues",
"definition": "An error code,from a specified code system, which details why the claim could not be adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
}
],
"strength": "example",
"description": "The adjudication error codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
}
},
{
"id": "ClaimResponse.totalCost",
"path": "ClaimResponse.totalCost",
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.unallocDeductable",
"path": "ClaimResponse.unallocDeductable",
"short": "Unallocated deductible",
"definition": "The amount of deductible applied which was not allocated to any particular service line.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.totalBenefit",
"path": "ClaimResponse.totalBenefit",
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible).",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
}
],
"path": "ClaimResponse.payment",
"short": "Payment details, if paid",
"definition": "Payment details for the claim if the claim has been paid.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.payment.id",
"path": "ClaimResponse.payment.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.payment.extension",
"path": "ClaimResponse.payment.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.payment.modifierExtension",
"path": "ClaimResponse.payment.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.payment.type",
"path": "ClaimResponse.payment.type",
"short": "Partial or Complete",
"definition": "Whether this represents partial or complete payment of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
}
],
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
}
},
{
"id": "ClaimResponse.payment.adjustment",
"path": "ClaimResponse.payment.adjustment",
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment.adjustmentReason",
"path": "ClaimResponse.payment.adjustmentReason",
"short": "Explanation for the non-claim adjustment",
"definition": "Reason for the payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
}
],
"strength": "example",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
}
},
{
"id": "ClaimResponse.payment.date",
"path": "ClaimResponse.payment.date",
"short": "Expected data of Payment",
"definition": "Estimated payment data.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ClaimResponse.payment.amount",
"path": "ClaimResponse.payment.amount",
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment.identifier",
"path": "ClaimResponse.payment.identifier",
"short": "Identifier of the payment instrument",
"definition": "Payment identifier.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ClaimResponse.reserved",
"path": "ClaimResponse.reserved",
"short": "Funds reserved status",
"definition": "Status of funds reservation (For provider, for Patient, None).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"id": "ClaimResponse.form",
"path": "ClaimResponse.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
}
},
{
"id": "ClaimResponse.processNote",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
}
],
"path": "ClaimResponse.processNote",
"short": "Processing notes",
"definition": "Note text.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
]
},
{
"id": "ClaimResponse.processNote.id",
"path": "ClaimResponse.processNote.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.processNote.extension",
"path": "ClaimResponse.processNote.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.processNote.modifierExtension",
"path": "ClaimResponse.processNote.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.processNote.number",
"path": "ClaimResponse.processNote.number",
"short": "Sequence Number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.processNote.type",
"path": "ClaimResponse.processNote.type",
"short": "display | print | printoper",
"definition": "The note purpose: Print/Display.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
}
},
{
"id": "ClaimResponse.processNote.text",
"path": "ClaimResponse.processNote.text",
"short": "Note explanatory text",
"definition": "The note text.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.processNote.language",
"path": "ClaimResponse.processNote.language",
"short": "Language if different from the resource",
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ClaimResponse.communicationRequest",
"path": "ClaimResponse.communicationRequest",
"short": "Request for additional information",
"definition": "Request for additional supporting or authorizing information, such as: documents, images or resources.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
}
]
},
{
"id": "ClaimResponse.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "ClaimResponse.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"constraint": [
{
"key": "ele-1",
"severity": "error",
"human": "All FHIR elements must have a @value or children",
"expression": "hasValue() | (children().count() > id.count())",
"xpath": "@value|f:*|h:div",
"source": "Element"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "ClaimResponse.insurance.id",
"path": "ClaimResponse.insurance.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.insurance.extension",
"path": "ClaimResponse.insurance.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "ClaimResponse.insurance.modifierExtension",
"path": "ClaimResponse.insurance.modifierExtension",
"short": "Extensions that cannot be ignored",
"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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"comment": "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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "ClaimResponse.insurance.sequence",
"path": "ClaimResponse.insurance.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.insurance.focal",
"path": "ClaimResponse.insurance.focal",
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ClaimResponse.insurance.coverage",
"path": "ClaimResponse.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "ClaimResponse.insurance.businessArrangement",
"path": "ClaimResponse.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.insurance.preAuthRef",
"path": "ClaimResponse.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.insurance.claimResponse",
"path": "ClaimResponse.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
}
]
},
"differential": {
"element": [
{
"id": "ClaimResponse",
"path": "ClaimResponse",
"short": "Remittance resource",
"definition": "This resource provides the adjudication details from the processing of a Claim resource.",
"alias": [
"Remittance Advice"
],
"min": 0,
"max": "*",
"mapping": [
{
"identity": "workflow",
"map": "Event"
},
{
"identity": "w5",
"map": "financial.billing"
}
]
},
{
"id": "ClaimResponse.identifier",
"path": "ClaimResponse.identifier",
"short": "Response number",
"definition": "The Response business identifier.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.identifier"
},
{
"identity": "w5",
"map": "FiveWs.identifier"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "ClaimResponse.status",
"path": "ClaimResponse.status",
"short": "active | cancelled | draft | entered-in-error",
"definition": "The status of the resource instance.",
"comment": "This element is labeled as a modifier because the status contains the code cancelled and entered-in-error that mark the response as not currently valid.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimResponseStatus"
}
],
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"mapping": [
{
"identity": "workflow",
"map": "Event.status"
},
{
"identity": "w5",
"map": "FiveWs.status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "ClaimResponse.patient",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint",
"valueString": "who.focus"
}
],
"path": "ClaimResponse.patient",
"short": "The subject of the Products and Services",
"definition": "Patient Resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
]
},
{
"id": "ClaimResponse.created",
"path": "ClaimResponse.created",
"short": "Creation date",
"definition": "The date when the enclosed suite of services were performed or completed.",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.occurrence[x]"
},
{
"identity": "w5",
"map": "FiveWs.recorded"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "ClaimResponse.insurer",
"path": "ClaimResponse.insurer",
"short": "Insurance issuing organization",
"definition": "The Insurer who produced this adjudicated response.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.performer"
}
]
},
{
"id": "ClaimResponse.requestProvider",
"path": "ClaimResponse.requestProvider",
"short": "Responsible practitioner",
"definition": "The practitioner who is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ClaimResponse.requestOrganization",
"path": "ClaimResponse.requestOrganization",
"short": "Responsible organization",
"definition": "The organization which is responsible for the services rendered to the patient.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "w5",
"map": "FiveWs.source"
},
{
"identity": "w5",
"map": "who.source"
}
]
},
{
"id": "ClaimResponse.request",
"path": "ClaimResponse.request",
"short": "Id of resource triggering adjudication",
"definition": "Original request resource referrence.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.basedOn"
},
{
"identity": "w5",
"map": "FiveWs.why[x]"
},
{
"identity": "w5",
"map": "why"
}
]
},
{
"id": "ClaimResponse.outcome",
"path": "ClaimResponse.outcome",
"short": "complete | error | partial",
"definition": "Transaction: error, complete, partial processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
}
],
"strength": "required",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
}
},
{
"id": "ClaimResponse.disposition",
"path": "ClaimResponse.disposition",
"short": "Disposition Message",
"definition": "A description of the status of the adjudication.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "workflow",
"map": "Event.note"
}
]
},
{
"id": "ClaimResponse.payeeType",
"path": "ClaimResponse.payeeType",
"short": "Party to be paid any benefits payable",
"definition": "Party to be reimbursed: Subscriber, provider, other.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
}
},
{
"id": "ClaimResponse.item",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
}
],
"path": "ClaimResponse.item",
"short": "Line items",
"definition": "The first tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.item.itemSequence",
"path": "ClaimResponse.item.itemSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.noteNumber",
"path": "ClaimResponse.item.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.adjudication",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
}
],
"path": "ClaimResponse.item.adjudication",
"short": "Adjudication details",
"definition": "The adjudication results.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.item.adjudication.category",
"path": "ClaimResponse.item.adjudication.category",
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"definition": "Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
}
],
"strength": "example",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
}
},
{
"id": "ClaimResponse.item.adjudication.reason",
"path": "ClaimResponse.item.adjudication.reason",
"short": "Explanation of Adjudication outcome",
"definition": "Adjudication reason such as limit reached.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
}
],
"strength": "example",
"description": "The adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
}
},
{
"id": "ClaimResponse.item.adjudication.amount",
"path": "ClaimResponse.item.adjudication.amount",
"short": "Monetary amount",
"definition": "Monetary amount associated with the code.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.item.adjudication.value",
"path": "ClaimResponse.item.adjudication.value",
"short": "Non-monetary value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above.",
"min": 0,
"max": "1",
"type": [
{
"code": "decimal"
}
]
},
{
"id": "ClaimResponse.item.detail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
}
],
"path": "ClaimResponse.item.detail",
"short": "Detail line items",
"definition": "The second tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.item.detail.detailSequence",
"path": "ClaimResponse.item.detail.detailSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.noteNumber",
"path": "ClaimResponse.item.detail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.adjudication",
"path": "ClaimResponse.item.detail.adjudication",
"short": "Detail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.item.detail.subDetail",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
}
],
"path": "ClaimResponse.item.detail.subDetail",
"short": "Subdetail line items",
"definition": "The third tier service adjudications for submitted services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"path": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"short": "Service instance",
"definition": "A service line number.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"short": "Subdetail level adjudication details",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.addItem",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
}
],
"path": "ClaimResponse.addItem",
"short": "Insurer added line items",
"definition": "The first tier service adjudications for payor added services.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.addItem.itemSequence",
"path": "ClaimResponse.addItem.itemSequence",
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.detailSequence",
"path": "ClaimResponse.addItem.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.subdetailSequence",
"path": "ClaimResponse.addItem.subdetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.service",
"path": "ClaimResponse.addItem.service",
"short": "Group, Service or Product",
"definition": "A code to indicate the Professional Service or Product supplied.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
}
],
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
}
},
{
"id": "ClaimResponse.addItem.modifier",
"path": "ClaimResponse.addItem.modifier",
"short": "Service/Product billing modifiers",
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"requirements": "May impact on adjudication.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
}
],
"strength": "example",
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"mapping": [
{
"identity": "rim",
"map": "24.C, 24.D mods"
}
]
},
{
"id": "ClaimResponse.addItem.fee",
"path": "ClaimResponse.addItem.fee",
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product..",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.addItem.noteNumber",
"path": "ClaimResponse.addItem.noteNumber",
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below.",
"min": 0,
"max": "*",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.addItem.adjudication",
"path": "ClaimResponse.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"min": 0,
"max": "*",
"contentReference": "#ClaimResponse.item.adjudication"
},
{
"id": "ClaimResponse.error",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
}
],
"path": "ClaimResponse.error",
"short": "Processing errors",
"definition": "Mutually exclusive with Services Provided (Item).",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.error.itemSequence",
"path": "ClaimResponse.error.itemSequence",
"short": "Item sequence number",
"definition": "The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.detailSequence",
"path": "ClaimResponse.error.detailSequence",
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.subDetailSequence",
"path": "ClaimResponse.error.subDetailSequence",
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.error.code",
"path": "ClaimResponse.error.code",
"short": "Error code detailing processing issues",
"definition": "An error code,from a specified code system, which details why the claim could not be adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
}
],
"strength": "example",
"description": "The adjudication error codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
}
},
{
"id": "ClaimResponse.totalCost",
"path": "ClaimResponse.totalCost",
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.unallocDeductable",
"path": "ClaimResponse.unallocDeductable",
"short": "Unallocated deductible",
"definition": "The amount of deductible applied which was not allocated to any particular service line.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.totalBenefit",
"path": "ClaimResponse.totalBenefit",
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible).",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
}
],
"path": "ClaimResponse.payment",
"short": "Payment details, if paid",
"definition": "Payment details for the claim if the claim has been paid.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.payment.type",
"path": "ClaimResponse.payment.type",
"short": "Partial or Complete",
"definition": "Whether this represents partial or complete payment of the claim.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
}
],
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
}
},
{
"id": "ClaimResponse.payment.adjustment",
"path": "ClaimResponse.payment.adjustment",
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment.adjustmentReason",
"path": "ClaimResponse.payment.adjustmentReason",
"short": "Explanation for the non-claim adjustment",
"definition": "Reason for the payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
}
],
"strength": "example",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
}
},
{
"id": "ClaimResponse.payment.date",
"path": "ClaimResponse.payment.date",
"short": "Expected data of Payment",
"definition": "Estimated payment data.",
"min": 0,
"max": "1",
"type": [
{
"code": "date"
}
]
},
{
"id": "ClaimResponse.payment.amount",
"path": "ClaimResponse.payment.amount",
"short": "Payable amount after adjustment",
"definition": "Payable less any payment adjustment.",
"min": 0,
"max": "1",
"type": [
{
"code": "Money"
}
]
},
{
"id": "ClaimResponse.payment.identifier",
"path": "ClaimResponse.payment.identifier",
"short": "Identifier of the payment instrument",
"definition": "Payment identifier.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"id": "ClaimResponse.reserved",
"path": "ClaimResponse.reserved",
"short": "Funds reserved status",
"definition": "Status of funds reservation (For provider, for Patient, None).",
"min": 0,
"max": "1",
"type": [
{
"code": "Coding"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
}
},
{
"id": "ClaimResponse.form",
"path": "ClaimResponse.form",
"short": "Printed Form Identifier",
"definition": "The form to be used for printing the content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "example",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
}
},
{
"id": "ClaimResponse.processNote",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
}
],
"path": "ClaimResponse.processNote",
"short": "Processing notes",
"definition": "Note text.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
]
},
{
"id": "ClaimResponse.processNote.number",
"path": "ClaimResponse.processNote.number",
"short": "Sequence Number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item.",
"min": 0,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.processNote.type",
"path": "ClaimResponse.processNote.type",
"short": "display | print | printoper",
"definition": "The note purpose: Print/Display.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
}
},
{
"id": "ClaimResponse.processNote.text",
"path": "ClaimResponse.processNote.text",
"short": "Note explanatory text",
"definition": "The note text.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.processNote.language",
"path": "ClaimResponse.processNote.language",
"short": "Language if different from the resource",
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
},
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "ClaimResponse.communicationRequest",
"path": "ClaimResponse.communicationRequest",
"short": "Request for additional information",
"definition": "Request for additional supporting or authorizing information, such as: documents, images or resources.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
}
]
},
{
"id": "ClaimResponse.insurance",
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
}
],
"path": "ClaimResponse.insurance",
"short": "Insurance or medical plan",
"definition": "Financial instrument by which payment information for health care.",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"mapping": [
{
"identity": "rim",
"map": "Coverage"
}
]
},
{
"id": "ClaimResponse.insurance.sequence",
"path": "ClaimResponse.insurance.sequence",
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages.",
"min": 1,
"max": "1",
"type": [
{
"code": "positiveInt"
}
]
},
{
"id": "ClaimResponse.insurance.focal",
"path": "ClaimResponse.insurance.focal",
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated.",
"min": 1,
"max": "1",
"type": [
{
"code": "boolean"
}
]
},
{
"id": "ClaimResponse.insurance.coverage",
"path": "ClaimResponse.insurance.coverage",
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
}
]
},
{
"id": "ClaimResponse.insurance.businessArrangement",
"path": "ClaimResponse.insurance.businessArrangement",
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.insurance.preAuthRef",
"path": "ClaimResponse.insurance.preAuthRef",
"short": "Pre-Authorization/Determination Reference",
"definition": "A list of references from the Insurer to which these services pertain.",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"max": "*",
"type": [
{
"code": "string"
}
]
},
{
"id": "ClaimResponse.insurance.claimResponse",
"path": "ClaimResponse.insurance.claimResponse",
"short": "Adjudication results",
"definition": "The Coverages adjudication details.",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
®© HL7.org 2011+. FHIR Release 4 Draft for Comment (Jan-2018 v3.2.0-12885) generated on Wed, Dec 20, 2017 15:56+1100. QA Page
Links: Search |
Version History |
Table of Contents |
Credits |
Compare to DSTU3 |
|
Propose a change