2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

7.15 Resource Readjudicate - Content

This resource maintained by the Financial Management Work Group

This resource provides the request and line items details for the claim which is to be re-adjudicated.

7.15.1 Scope and Usage

The Readjudicate resource indicates the claim which is to be reversed and provides both supporting information for the reversal and the goods and services which are to be readjudicated.

This is necessary for the limited supporters who require the ability to formally request the re-adjudication of specified service sub-trees from an already adjudicated Claim.

Todo

7.15.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Readjudicate DomainResourceReadjudicate request
... identifier 0..*IdentifierBusiness Identifier
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible practitioner
... organization 0..1OrganizationResponsible organization
... request 0..1AnyRequest reference
... response 0..1AnyResponse reference
... reference 0..1stringReference number/string
... item 0..*ElementItems to re-adjudicate
.... sequenceLinkId 1..1integerService instance

XML Template

<Readjudicate xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <request><!-- 0..1 Reference(Any) Request reference --></request>
 <response><!-- 0..1 Reference(Any) Response reference --></response>
 <reference value="[string]"/><!-- 0..1 Reference number/string -->
 <item>  <!-- 0..* Items to re-adjudicate -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
 </item>
</Readjudicate>

JSON Template

{doco
  "resourceType" : "Readjudicate",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Any) }, // Request reference
  "response" : { Reference(Any) }, // Response reference
  "reference" : "<string>", // Reference number/string
  "item" : [{ // Items to re-adjudicate
    "sequenceLinkId" : <integer> // R! Service instance
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. Readjudicate DomainResourceReadjudicate request
... identifier 0..*IdentifierBusiness Identifier
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... target 0..1OrganizationInsurer
... provider 0..1PractitionerResponsible practitioner
... organization 0..1OrganizationResponsible organization
... request 0..1AnyRequest reference
... response 0..1AnyResponse reference
... reference 0..1stringReference number/string
... item 0..*ElementItems to re-adjudicate
.... sequenceLinkId 1..1integerService instance

XML Template

<Readjudicate xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier --></identifier>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <target><!-- 0..1 Reference(Organization) Insurer --></target>
 <provider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></provider>
 <organization><!-- 0..1 Reference(Organization) Responsible organization --></organization>
 <request><!-- 0..1 Reference(Any) Request reference --></request>
 <response><!-- 0..1 Reference(Any) Response reference --></response>
 <reference value="[string]"/><!-- 0..1 Reference number/string -->
 <item>  <!-- 0..* Items to re-adjudicate -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
 </item>
</Readjudicate>

JSON Template

{doco
  "resourceType" : "Readjudicate",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "target" : { Reference(Organization) }, // Insurer
  "provider" : { Reference(Practitioner) }, // Responsible practitioner
  "organization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Any) }, // Request reference
  "response" : { Reference(Any) }, // Response reference
  "reference" : "<string>", // Reference number/string
  "item" : [{ // Items to re-adjudicate
    "sequenceLinkId" : <integer> // R! Service instance
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.15.2.1 Terminology Bindings

PathDefinitionTypeReference
Readjudicate.ruleset
Readjudicate.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset

7.15.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe business identifier of the EligibilityReadjudicate.identifier