This page is part of the Consumer Real-time Pharmacy Benefit Check (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions 
SD.1 StructureDefinition-carin-rtpbc-response-claimresponse
This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process.
Data population is similar to a typical predetermination ClaimResponse request (where the corresponding Claim.use was set to “predetermination”), with the following key differences:
- in addition to cost and coverage for the requested medication and pharmacy, the responder may also return information about *alternative” medication + pharmacy combinations. These alternatives are conveyed in one or more ClaimResponse.addItem composites, characterized as independent options using an extension defined in this guide (isAlternative
- the processNote element is used to communicate the level at which the requested drug and pharmacy are covered, as well as alternative drug/pharmacy combinations (using high-level, pre-defined coverage statements tailored to the patient’s perspective
- alternative pharmacies are communicated using referenced Organization resources
- certain other elements are fixed to values reflecting a medication-related request…
ClaimResponse.type = “pharmacy”
ClaimResponse.addItem elements are constrained to product identifiers and quantity units of measure describing medications.
In this profile, the ClaimResponse references the following supported resources, both of which are profiled in this guide:
- Patient (containing a small amount of identifying information to enable the insurer to locate the patient’s records)
- Organization (identifying an alternative pharmacy)
Must Support elements in this profile
Responding systems
- Responders SHOULD return pricing and coverage information for relevant drug/pharmacy alternatives, in the addItem composite
- The error composite MUST be populated when the responder cannot complete processing due to a business rule or data exception. Otherwise, the item composite MUST be populated
- The processNote element is a conditional element that MUST be populated when the responder is an insurer (or other processor representing the patient’s pharmacy benefit). It is not expected to be populated when the responder is a medication pricing source
- All elements with a minimum cardinality of 1 that are also marked Must Support are essential to communicating patient costs and coverage. The responder MUST ensure that content in these elements is accurate and complete
Client systems
- MUST be able to interpret and convey to users all cost and coverage information returned in the response, as appropriate to the application
SD.1.1 Formal Views of Profile Content
Description of Profiles, Differentials, and Snapshots.
The official URL for this profile is: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-response
Published on Sun Dec 08 05:00:00 UTC 2019 as a active by CARIN Alliance.
This profile builds on ClaimResponse
Summary
Mandatory: 9 elements (26 nested mandatory elements)
Must-Support: 53 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
- http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-patient
- http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-pharmacy
Extensions
This structure refers to these extensions:
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ClaimResponse | 0..* | ClaimResponse | ||
  id | S | 0..1 | string | Unique ClaimResponse Resource Identifier |
| identifier | S | 1..* | Identifier | RTPBC Response Identifier |
  value | S | 1..1 | string | Unique RTPBC response ID |
| status | S | 1..1 | code | Response status Fixed Value: active |
| type | S | 1..1 | CodeableConcept | Requested Service Type Fixed Value: As shown |
 coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | |
| coding | S | 1..* | Coding | |
 system | S | 1..1 | uri | |
| code | S | 1..1 | code | |
| use | S | 1..1 | code | Processing Mode Fixed Value: predetermination |
 patient | S | 1..1 | Reference(CARIN RTPBC Patient) | Response Patient Information |
| insurer | 1..1 | Reference(Organization) | ||
| identifier | 0..1 | Identifier | ||
| value | S | 1..1 | string | Payer ID |
| request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID |
| identifier | S | 1..1 | Identifier | |
| value | S | 1..1 | string | RTPBC Request ID |
| outcome | S | 1..1 | code | Processing Outcome |
| disposition | S | 0..1 | string | Completed Note |
| item | S | 0..* | BackboneElement | Requested Product and Pharmacy |
| itemSequence | S | 1..1 | positiveInt | |
| noteNumber | S | 1..* | positiveInt | Determination Note Number |
| adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination |
| category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| amount | S | 1..1 | Money | Patient Pay Component Amount |
| value | S | 1..1 | decimal | Patient Pay Amount Value |
| currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| addItem | 0..* | BackboneElement | ||
 extension | S | 0..* | Extension | |
 rtpbc-isAlternative | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative |
| itemSequence | S | 1..* | positiveInt | Associated request Item Sequence |
| provider | S | 1..* | Reference(CARIN RTPBC PharmacyOrganization) | Priced Pharmacy |
| reference | S | 1..1 | string | Reference to Priced Pharmacy |
| productOrService | S | 1..1 | CodeableConcept | Product Binding: CARIN RTPBC Prescribable Product Code Value Set (required) |
| coding | S | 1..* | Coding | |
| system | S | 1..1 | uri | |
| code | S | 1..1 | code | |
| display | S | 1..1 | string | Product Description |
| quantity | S | 1..1 | SimpleQuantity | Priced Quantity |
| value | S | 1..1 | decimal | Quantity in Billing Units |
| unit | S | 1..1 | string | Billing unit of measure Binding: CARIN RTPBC Billing Unit Value Set (extensible) |
| noteNumber | S | 1..* | positiveInt | Determination Note Number |
| adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination |
| category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| amount | S | 1..1 | Money | Patient Pay Component Amount |
| value | S | 1..1 | decimal | Patient Pay Amount Value |
| currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| processNote | S | 0..* | BackboneElement | Determination Note |
| number | S | 1..1 | positiveInt | Determination Note Number |
| text | S | 1..1 | string | Determination Note Text Binding: CARIN RTPBC Coverage Summary Value Set (extensible) |
| error | S | 0..* | BackboneElement | Error Information |
| code | S | 1..1 | CodeableConcept | Reject Reason Binding: CARIN RTPBC Error Code Value Set (preferred) |
| coding | S | 1..* | Coding | |
| system | S | 1..1 | uri | |
| code | S | 1..1 | code | Reject Code |
| display | S | 1..1 | string | |
| text | S | 0..1 | string | Reject Message |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | I | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization |
 id | SΣ | 0..1 | string | Unique ClaimResponse Resource Identifier |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | Identifier | RTPBC Response Identifier |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Unique RTPBC response ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!SΣI | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required) Fixed Value: active |
| type | SΣI | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible) Fixed Value: As shown |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Symbol in syntax defined by the system |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | SΣI | 1..1 | code | Processing Mode Binding: Use (required) Fixed Value: predetermination |
| patient | SΣI | 1..1 | Reference(CARIN RTPBC Patient) | Response Patient Information |
| created | ΣI | 1..1 | dateTime | Response creation date |
| insurer | ΣI | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Payer ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| requestor | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| request | SΣI | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | SΣI | 1..1 | Identifier | Logical reference, when literal reference is not known |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | RTPBC Request ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| outcome | SΣI | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required) |
| disposition | SI | 0..1 | string | Completed Note |
| preAuthRef | I | 0..1 | string | Preauthorization reference |
| preAuthPeriod | I | 0..1 | Period | Preauthorization reference effective period |
| payeeType | I | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example) |
| item | SI | 0..* | BackboneElement | Requested Product and Pharmacy |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | SI | 1..1 | positiveInt | Claim item instance identifier |
| noteNumber | SI | 1..* | positiveInt | Determination Note Number |
| adjudication | SI | 1..* | BackboneElement | Requested Product and Pharmacy Determination |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 1..1 | Money | Patient Pay Component Amount |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Patient Pay Amount Value |
| currency | SΣI | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| value | I | 0..1 | decimal | Non-monetary value |
| detail | I | 0..* | BackboneElement | Adjudication for claim details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| detailSequence | I | 1..1 | positiveInt | Claim detail instance identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Detail level adjudication details | |
| subDetail | I | 0..* | BackboneElement | Adjudication for claim sub-details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| subDetailSequence | I | 1..1 | positiveInt | Claim sub-detail instance identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ClaimResponse.item.adjudication Subdetail level adjudication details | |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | SI | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| rtpbc-isAlternative | SI | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | SI | 1..* | positiveInt | Associated request Item Sequence |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subdetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | SI | 1..* | Reference(CARIN RTPBC PharmacyOrganization) | Priced Pharmacy |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | SΣI | 1..1 | string | Reference to Priced Pharmacy |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| productOrService | SI | 1..1 | CodeableConcept | Product Binding: CARIN RTPBC Prescribable Product Code Value Set (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Symbol in syntax defined by the system |
| display | SΣI | 1..1 | string | Product Description |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
 serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | SI | 1..1 | SimpleQuantity | Priced Quantity |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Quantity in Billing Units |
| unit | SΣI | 1..1 | string | Billing unit of measure Binding: CARIN RTPBC Billing Unit Value Set (extensible) |
| system | ΣI | 0..1 | uri | System that defines coded unit form |
| code | ΣI | 0..1 | code | Coded form of the unit |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | SI | 1..* | positiveInt | Determination Note Number |
| adjudication | SI | 1..* | BackboneElement | Alternative Product and Pharmacy Determination |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 1..1 | Money | Patient Pay Component Amount |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Patient Pay Amount Value |
| currency | SΣI | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| value | I | 0..1 | decimal | Non-monetary value |
| detail | I | 0..* | BackboneElement | Insurer added line details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Added items detail adjudication | |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Added items detail adjudication | |
| adjudication | I | 0..* | Unknown reference to #ClaimResponse.item.adjudication Header-level adjudication | |
| total | ΣI | 0..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | I | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 1..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | SI | 0..* | BackboneElement | Determination Note |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | SI | 1..1 | positiveInt | Determination Note Number |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | SI | 1..1 | string | Determination Note Text Binding: CARIN RTPBC Coverage Summary Value Set (extensible) |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| communicationRequest | I | 0..* | Reference(CommunicationRequest) | Request for additional information |
| insurance | I | 0..* | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Insurance instance identifier |
| focal | I | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | I | 1..1 | Reference(Coverage) | Insurance information |
| businessArrangement | I | 0..1 | string | Additional provider contract number |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Adjudication results |
| error | SI | 0..* | BackboneElement | Error Information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..1 | positiveInt | Item sequence number |
| detailSequence | I | 0..1 | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..1 | positiveInt | Subdetail sequence number |
| code | SI | 1..1 | CodeableConcept | Reject Reason Binding: CARIN RTPBC Error Code Value Set (preferred) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Reject Code |
| display | SΣI | 1..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Reject Message |
| Documentation for this format | ||||
Summary
Mandatory: 9 elements (26 nested mandatory elements)
Must-Support: 53 elements
Fixed Value: 3 elements
Structures
This structure refers to these other structures:
- http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-patient
- http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-pharmacy
Extensions
This structure refers to these extensions:
Differential View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | 0..* | ClaimResponse | ||
| id | S | 0..1 | string | Unique ClaimResponse Resource Identifier |
| identifier | S | 1..* | Identifier | RTPBC Response Identifier |
| value | S | 1..1 | string | Unique RTPBC response ID |
| status | S | 1..1 | code | Response status Fixed Value: active |
| type | S | 1..1 | CodeableConcept | Requested Service Type Fixed Value: As shown |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | |
| coding | S | 1..* | Coding | |
| system | S | 1..1 | uri | |
| code | S | 1..1 | code | |
| use | S | 1..1 | code | Processing Mode Fixed Value: predetermination |
| patient | S | 1..1 | Reference(CARIN RTPBC Patient) | Response Patient Information |
| insurer | 1..1 | Reference(Organization) | ||
| identifier | 0..1 | Identifier | ||
| value | S | 1..1 | string | Payer ID |
| request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID |
| identifier | S | 1..1 | Identifier | |
| value | S | 1..1 | string | RTPBC Request ID |
| outcome | S | 1..1 | code | Processing Outcome |
| disposition | S | 0..1 | string | Completed Note |
| item | S | 0..* | BackboneElement | Requested Product and Pharmacy |
| itemSequence | S | 1..1 | positiveInt | |
| noteNumber | S | 1..* | positiveInt | Determination Note Number |
| adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination |
| category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| amount | S | 1..1 | Money | Patient Pay Component Amount |
| value | S | 1..1 | decimal | Patient Pay Amount Value |
| currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| addItem | 0..* | BackboneElement | ||
| extension | S | 0..* | Extension | |
| rtpbc-isAlternative | S | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative |
| itemSequence | S | 1..* | positiveInt | Associated request Item Sequence |
| provider | S | 1..* | Reference(CARIN RTPBC PharmacyOrganization) | Priced Pharmacy |
| reference | S | 1..1 | string | Reference to Priced Pharmacy |
| productOrService | S | 1..1 | CodeableConcept | Product Binding: CARIN RTPBC Prescribable Product Code Value Set (required) |
| coding | S | 1..* | Coding | |
| system | S | 1..1 | uri | |
| code | S | 1..1 | code | |
| display | S | 1..1 | string | Product Description |
| quantity | S | 1..1 | SimpleQuantity | Priced Quantity |
| value | S | 1..1 | decimal | Quantity in Billing Units |
| unit | S | 1..1 | string | Billing unit of measure Binding: CARIN RTPBC Billing Unit Value Set (extensible) |
| noteNumber | S | 1..* | positiveInt | Determination Note Number |
| adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination |
| category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| amount | S | 1..1 | Money | Patient Pay Component Amount |
| value | S | 1..1 | decimal | Patient Pay Amount Value |
| currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| processNote | S | 0..* | BackboneElement | Determination Note |
| number | S | 1..1 | positiveInt | Determination Note Number |
| text | S | 1..1 | string | Determination Note Text Binding: CARIN RTPBC Coverage Summary Value Set (extensible) |
| error | S | 0..* | BackboneElement | Error Information |
| code | S | 1..1 | CodeableConcept | Reject Reason Binding: CARIN RTPBC Error Code Value Set (preferred) |
| coding | S | 1..* | Coding | |
| system | S | 1..1 | uri | |
| code | S | 1..1 | code | Reject Code |
| display | S | 1..1 | string | |
| text | S | 0..1 | string | Reject Message |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ClaimResponse | I | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization |
| id | SΣ | 0..1 | string | Unique ClaimResponse Resource Identifier |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | Identifier | RTPBC Response Identifier |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Unique RTPBC response ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!SΣI | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required) Fixed Value: active |
| type | SΣI | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible) Fixed Value: As shown |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| coding | 1..1 | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..0 | string | Unique id for inter-element referencing | |
| extension | 0..0 | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| version | 0..0 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy | |
| userSelected | 0..0 | boolean | If this coding was chosen directly by the user | |
| text | 0..0 | string | Plain text representation of the concept | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Symbol in syntax defined by the system |
| display | ΣI | 0..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | SΣI | 1..1 | code | Processing Mode Binding: Use (required) Fixed Value: predetermination |
| patient | SΣI | 1..1 | Reference(CARIN RTPBC Patient) | Response Patient Information |
| created | ΣI | 1..1 | dateTime | Response creation date |
| insurer | ΣI | 1..1 | Reference(Organization) | Party responsible for reimbursement |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | Payer ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| requestor | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
| request | SΣI | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | ΣI | 0..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | SΣI | 1..1 | Identifier | Logical reference, when literal reference is not known |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | RTPBC Request ID Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| outcome | SΣI | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required) |
| disposition | SI | 0..1 | string | Completed Note |
| preAuthRef | I | 0..1 | string | Preauthorization reference |
| preAuthPeriod | I | 0..1 | Period | Preauthorization reference effective period |
| payeeType | I | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example) |
| item | SI | 0..* | BackboneElement | Requested Product and Pharmacy |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | SI | 1..1 | positiveInt | Claim item instance identifier |
| noteNumber | SI | 1..* | positiveInt | Determination Note Number |
| adjudication | SI | 1..* | BackboneElement | Requested Product and Pharmacy Determination |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 1..1 | Money | Patient Pay Component Amount |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Patient Pay Amount Value |
| currency | SΣI | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| value | I | 0..1 | decimal | Non-monetary value |
| detail | I | 0..* | BackboneElement | Adjudication for claim details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| detailSequence | I | 1..1 | positiveInt | Claim detail instance identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Detail level adjudication details | |
| subDetail | I | 0..* | BackboneElement | Adjudication for claim sub-details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| subDetailSequence | I | 1..1 | positiveInt | Claim sub-detail instance identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | Unknown reference to #ClaimResponse.item.adjudication Subdetail level adjudication details | |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | SI | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
| rtpbc-isAlternative | SI | 1..1 | boolean | Extension URL: http://hl7.org/fhir/us/carin/StructureDefinition/rtpbc-isAlternative |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | SI | 1..* | positiveInt | Associated request Item Sequence |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subdetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | SI | 1..* | Reference(CARIN RTPBC PharmacyOrganization) | Priced Pharmacy |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | SΣI | 1..1 | string | Reference to Priced Pharmacy |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| productOrService | SI | 1..1 | CodeableConcept | Product Binding: CARIN RTPBC Prescribable Product Code Value Set (required) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Symbol in syntax defined by the system |
| display | SΣI | 1..1 | string | Product Description |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | SI | 1..1 | SimpleQuantity | Priced Quantity |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Quantity in Billing Units |
| unit | SΣI | 1..1 | string | Billing unit of measure Binding: CARIN RTPBC Billing Unit Value Set (extensible) |
| system | ΣI | 0..1 | uri | System that defines coded unit form |
| code | ΣI | 0..1 | code | Coded form of the unit |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | SI | 1..* | positiveInt | Determination Note Number |
| adjudication | SI | 1..* | BackboneElement | Alternative Product and Pharmacy Determination |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Patient Pay Component Binding: CARIN RTPBC Patient Pay Type Value Set (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 1..1 | Money | Patient Pay Component Amount |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| value | SΣI | 1..1 | decimal | Patient Pay Amount Value |
| currency | SΣI | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required) |
| value | I | 0..1 | decimal | Non-monetary value |
| detail | I | 0..* | BackboneElement | Insurer added line details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Added items detail adjudication | |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 1..* | Unknown reference to #ClaimResponse.item.adjudication Added items detail adjudication | |
| adjudication | I | 0..* | Unknown reference to #ClaimResponse.item.adjudication Header-level adjudication | |
| total | ΣI | 0..* | BackboneElement | Adjudication totals |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example) |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | I | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | I | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example) |
| date | I | 0..1 | date | Expected date of payment |
| amount | I | 1..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | SI | 0..* | BackboneElement | Determination Note |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | SI | 1..1 | positiveInt | Determination Note Number |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | SI | 1..1 | string | Determination Note Text Binding: CARIN RTPBC Coverage Summary Value Set (extensible) |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| communicationRequest | I | 0..* | Reference(CommunicationRequest) | Request for additional information |
| insurance | I | 0..* | BackboneElement | Patient insurance information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Insurance instance identifier |
| focal | I | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | I | 1..1 | Reference(Coverage) | Insurance information |
| businessArrangement | I | 0..1 | string | Additional provider contract number |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Adjudication results |
| error | SI | 0..* | BackboneElement | Error Information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..1 | positiveInt | Item sequence number |
| detailSequence | I | 0..1 | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..1 | positiveInt | Subdetail sequence number |
| code | SI | 1..1 | CodeableConcept | Reject Reason Binding: CARIN RTPBC Error Code Value Set (preferred) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| system | SΣI | 1..1 | uri | Identity of the terminology system |
| version | ΣI | 0..1 | string | Version of the system - if relevant |
| code | SΣI | 1..1 | code | Reject Code |
| display | SΣI | 1..1 | string | Representation defined by the system |
| userSelected | ΣI | 0..1 | boolean | If this coding was chosen directly by the user |
| text | SΣI | 0..1 | string | Reject Message |
| Documentation for this format | ||||
Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron
