LinuxForHealth FHIR Implementation Guide
8.0.0 - draft United States of America flag

LinuxForHealth FHIR Implementation Guide - Local Development build (v8.0.0). See the Directory of published versions

Resource Profile: CDMClaimResponseDrug - Detailed Descriptions

Active as of 2022-11-10

Definitions for the cdm-claim-response-drug resource profile.

1. ClaimResponse
2. ClaimResponse.item
Control0..?
3. ClaimResponse.item.extension:usualAndCustomaryAmount
SliceNameusualAndCustomaryAmount
Definition

Usual and customary amount on the drug claim

Control0..1
TypeExtension(UsualAndCustomaryAmount) (Extension Type: decimal)
4. ClaimResponse.item.extension:rxFormularyIndicator
SliceNamerxFormularyIndicator
Definition

Indicates whether the prescription drug is included in the formulary

Control0..1
TypeExtension(RxFormularyIndicator) (Extension Type: string)
5. ClaimResponse.item.extension:rxPayTier
SliceNamerxPayTier
Definition

Customer-specific code for the payment tier of the drug Claim

Control0..1
TypeExtension(RxPayTier) (Extension Type: CodeableConcept)
6. ClaimResponse.item.extension:rxSupplyIndicator
SliceNamerxSupplyIndicator
Definition

Indicates whether the drug claim is a medical supply (Y) or a drug (N)

Control0..1
TypeExtension(RxSupplyIndicator) (Extension Type: string)
1. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

Control0..*
Alternate NamesRemittance Advice
InvariantsDefined on this element
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (: text.`div`.exists())
2. ClaimResponse.implicitRules
Definition

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

Control0..1
Typeuri
Is Modifiertrue
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. ClaimResponse.contained
Definition

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

Control0..0*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
Comments

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

4. ClaimResponse.extension:claimReceivedDate
SliceNameclaimReceivedDate
Definition

Date the claim was received

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimReceivedDate) (Extension Type: date)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
5. ClaimResponse.extension:claimStatus
SliceNameclaimStatus
Definition

Custom code for the claim status

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimStatus) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
6. ClaimResponse.extension:daysToProcess
SliceNamedaysToProcess
Definition

Number of days between the date the claim was received and the date the claim was processed

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(DaysToProcess) (Extension Type: integer)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
7. ClaimResponse.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensions, user content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
8. ClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..*
TypeIdentifier
Requirements

Allows claim responses to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. ClaimResponse.identifier.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. ClaimResponse.identifier.system
Definition

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

Control10..1
Typeuri
Requirements

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

Comments

Identifier.system is always case sensitive.

Example
General:http://www.acme.com/identifiers/patient
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. ClaimResponse.identifier.value
Definition

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

Control10..1
Typestring
Comments

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

Example
General:123456
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
12. ClaimResponse.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. ClaimResponse.type
Definition

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

Control1..1
BindingThe codes SHALL be taken from Claim Type Value Set; other codes may be used where these codes are not suitableThe codes SHALL be taken from ClaimTypeCodes; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. ClaimResponse.use
Definition

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

Control1..1
BindingThe codes SHALL be taken from Use

Claim, preauthorization, predetermination.

Typecode
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. ClaimResponse.patient
Definition

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

Control1..1
TypeReference(Patient))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. ClaimResponse.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Control1..1
TypeReference(Organization))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. ClaimResponse.outcome
Definition

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

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes

The result of the claim processing.

Typecode
Requirements

To advise the requestor of an overall processing outcome.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
1. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

Control0..*
Alternate NamesRemittance Advice
2. ClaimResponse.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Control0..1
Typeid
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

3. ClaimResponse.meta
Definition

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

Control0..1 This element is affected by the following invariants: ele-1
TypeMeta(ProcessMeta)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. ClaimResponse.implicitRules
Definition

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

Control0..1
Typeuri
Is Modifiertrue
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. ClaimResponse.language
Definition

The base language in which the resource is written.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. ClaimResponse.text
Definition

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

Control0..1
TypeNarrative
Alternate Namesnarrativehtmlxhtmldisplay
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. ClaimResponse.contained
Definition

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

Control0..0
TypeResource
Alternate Namesinline resourcesanonymous resourcescontained resources
Comments

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

8. ClaimResponse.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
9. ClaimResponse.extension:claimReceivedDate
SliceNameclaimReceivedDate
Definition

Date the claim was received

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimReceivedDate) (Extension Type: date)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
10. ClaimResponse.extension:claimStatus
SliceNameclaimStatus
Definition

Custom code for the claim status

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimStatus) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
11. ClaimResponse.extension:daysToProcess
SliceNamedaysToProcess
Definition

Number of days between the date the claim was received and the date the claim was processed

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(DaysToProcess) (Extension Type: integer)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
12. ClaimResponse.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
13. ClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..*
TypeIdentifier
Requirements

Allows claim responses to be distinguished and referenced.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. ClaimResponse.identifier.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
15. ClaimResponse.identifier.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.identifier.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
16. ClaimResponse.identifier.use
Definition

The purpose of this identifier.

Control0..1
BindingThe codes SHALL be taken from IdentifierUse Identifies the purpose for this identifier, if known
Typecode
Is Modifiertrue
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. ClaimResponse.identifier.type
Definition

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

Control0..1
BindingThe codes SHALL be taken from Identifier Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. ClaimResponse.identifier.system
Definition

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

Control1..1
Typeuri
Requirements

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

Comments

Identifier.system is always case sensitive.

Example
General:http://www.acme.com/identifiers/patient
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. ClaimResponse.identifier.value
Definition

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

Control1..1
Typestring
Comments

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

Example
General:123456
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. ClaimResponse.identifier.period
Definition

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

Control0..1
TypePeriod
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. ClaimResponse.identifier.assigner
Definition

Organization that issued/manages the identifier.

Control0..1
TypeReference(Organization))
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. ClaimResponse.status
Definition

The status of the resource instance.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes A code specifying the state of the resource instance
Typecode
Is Modifiertrue
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
23. ClaimResponse.type
Definition

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

Control1..1
BindingThe codes SHALL be taken from Claim Type Value Set; other codes may be used where these codes are not suitable
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
24. ClaimResponse.subType
Definition

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

Control0..1
BindingFor example codes, see ExampleClaimSubTypeCodes A more granular claim typecode
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
25. ClaimResponse.use
Definition

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

Control1..1
BindingThe codes SHALL be taken from Use Claim, preauthorization, predetermination
Typecode
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. ClaimResponse.patient
Definition

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

Control1..1
TypeReference(Patient))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. ClaimResponse.created
Definition

The date this resource was created.

Control1..1
TypedateTime
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

Control1..1
TypeReference(Organization))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. ClaimResponse.requestor
Definition

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

Control0..1
TypeReference(PractitionerPractitionerRoleOrganization))
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. ClaimResponse.request
Definition

Original request resource reference.

Control0..1
TypeReference(Claim))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
31. ClaimResponse.outcome
Definition

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

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes The result of the claim processing
Typecode
Requirements

To advise the requestor of an overall processing outcome.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
32. ClaimResponse.disposition
Definition

A human readable description of the status of the adjudication.

Control0..1
Typestring
Requirements

Provided for user display.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
33. ClaimResponse.preAuthRef
Definition

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

Control0..1
Typestring
Requirements

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

Comments

This value is only present on preauthorization adjudications.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. ClaimResponse.preAuthPeriod
Definition

The time frame during which this authorization is effective.

Control0..1
TypePeriod
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. ClaimResponse.payeeType
Definition

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

Control0..1
BindingFor example codes, see Claim Payee Type Codes A code for the party to be reimbursed
TypeCodeableConcept
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. ClaimResponse.item
Definition

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

Control0..*
TypeBackboneElement
Requirements

The adjudication for items provided on the claim.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
37. ClaimResponse.item.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
38. ClaimResponse.item.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.item.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
39. ClaimResponse.item.extension:claimResponseItemStatus
SliceNameclaimResponseItemStatus
Definition

The status of claim payment on claim item

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimResponseItemStatus) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
40. ClaimResponse.item.extension:claimResponseBenefitPlan
SliceNameclaimResponseBenefitPlan
Definition

The benefit plan that covers the service rendered

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ClaimResponseBenefitPlan) (Extension Type: Reference(Coverage)))
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
41. ClaimResponse.item.extension:copayExclusion
SliceNamecopayExclusion
Definition

Customer-specific code for the exclusion reason of a copayment

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(CopayExclusion) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
42. ClaimResponse.item.extension:numberOfUnitsAllowed
SliceNamenumberOfUnitsAllowed
Definition

Customer-specific quantity of services or units allowed

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(NumberOfUnitsAllowed) (Extension Type: integer)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
43. ClaimResponse.item.extension:reinsuranceMetIndicator
SliceNamereinsuranceMetIndicator
Definition

Indicator that the reinsurance amount was met

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ReinsuranceMetIndicator) (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
44. ClaimResponse.item.extension:utilizationReview
SliceNameutilizationReview
Definition

Customer-specific code for the type of utilization review

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(UtilizationReview) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
45. ClaimResponse.item.extension:usualAndCustomaryAmount
SliceNameusualAndCustomaryAmount
Definition

Usual and customary amount on the drug claim

Control0..1
TypeExtension(UsualAndCustomaryAmount) (Extension Type: decimal)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
46. ClaimResponse.item.extension:rxFormularyIndicator
SliceNamerxFormularyIndicator
Definition

Indicates whether the prescription drug is included in the formulary

Control0..1
TypeExtension(RxFormularyIndicator) (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
47. ClaimResponse.item.extension:rxPayTier
SliceNamerxPayTier
Definition

Customer-specific code for the payment tier of the drug Claim

Control0..1
TypeExtension(RxPayTier) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
48. ClaimResponse.item.extension:rxSupplyIndicator
SliceNamerxSupplyIndicator
Definition

Indicates whether the drug claim is a medical supply (Y) or a drug (N)

Control0..1
TypeExtension(RxSupplyIndicator) (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
49. ClaimResponse.item.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
50. ClaimResponse.item.itemSequence
Definition

A number to uniquely reference the claim item entries.

Control1..1
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
51. ClaimResponse.item.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
52. ClaimResponse.item.adjudication
Definition

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

Control1..*
TypeBackboneElement
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
53. ClaimResponse.item.adjudication.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
54. ClaimResponse.item.adjudication.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.item.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
55. ClaimResponse.item.adjudication.extension:routingNumberCode
SliceNameroutingNumberCode
Definition

Customer-specific code for the ITS routing number

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(RoutingNumberCode) (Extension Type: string)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
56. ClaimResponse.item.adjudication.extension:savingsType
SliceNamesavingsType
Definition

Customer-specific code for the type of third party savings

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(SavingsType) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
57. ClaimResponse.item.adjudication.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
58. ClaimResponse.item.adjudication.category
Definition

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

Control1..1
BindingFor example codes, see Adjudication Category Value Set
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
59. ClaimResponse.item.adjudication.reason
Definition

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

Control0..1
BindingFor example codes, see AdjudicationReasonCodes The adjudication reason codes
TypeCodeableConcept
Requirements

To support understanding of variance from adjudication expectations.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
60. ClaimResponse.item.adjudication.amount
Definition

Monetary amount associated with the category.

Control0..1
TypeMoney
Requirements

Most adjuciation categories convey a monetary amount.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
61. ClaimResponse.item.adjudication.value
Definition

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

Control0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
62. ClaimResponse.item.detail
Definition

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

Control0..*
TypeBackboneElement
Requirements

The adjudication for details provided on the claim.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
63. ClaimResponse.item.detail.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
64. ClaimResponse.item.detail.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
65. ClaimResponse.item.detail.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
66. ClaimResponse.item.detail.detailSequence
Definition

A number to uniquely reference the claim detail entry.

Control1..1
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
67. ClaimResponse.item.detail.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
68. ClaimResponse.item.detail.adjudication
Definition

The adjudication results.

Control1..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
69. ClaimResponse.item.detail.subDetail
Definition

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

Control0..*
TypeBackboneElement
Requirements

The adjudication for sub-details provided on the claim.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
70. ClaimResponse.item.detail.subDetail.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
71. ClaimResponse.item.detail.subDetail.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
72. ClaimResponse.item.detail.subDetail.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
73. ClaimResponse.item.detail.subDetail.subDetailSequence
Definition

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

Control1..1
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
74. ClaimResponse.item.detail.subDetail.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
75. ClaimResponse.item.detail.subDetail.adjudication
Definition

The adjudication results.

Control0..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
76. ClaimResponse.addItem
Definition

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

Control0..*
TypeBackboneElement
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
77. ClaimResponse.addItem.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
78. ClaimResponse.addItem.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
79. ClaimResponse.addItem.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
80. ClaimResponse.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

Control0..*
TypepositiveInt
Requirements

Provides references to the claim items.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
81. ClaimResponse.addItem.detailSequence
Definition

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

Control0..*
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
82. ClaimResponse.addItem.subdetailSequence
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
83. ClaimResponse.addItem.provider
Definition

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

Control0..*
TypeReference(PractitionerPractitionerRoleOrganization))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
84. ClaimResponse.addItem.productOrService
Definition

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

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
85. ClaimResponse.addItem.modifier
Definition

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

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
86. ClaimResponse.addItem.programCode
Definition

Identifies the program under which this may be recovered.

Control0..*
BindingFor example codes, see ExampleProgramReasonCodes Program specific reason codes
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
87. ClaimResponse.addItem.serviced[x]
Definition

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

Control0..1
TypeChoice of: date, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
88. ClaimResponse.addItem.location[x]
Definition

Where the product or service was provided.

Control0..1
BindingFor example codes, see ExampleServicePlaceCodes Place of service: pharmacy, school, prison, etc
TypeChoice of: CodeableConcept, Address, Reference(Location))
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
89. ClaimResponse.addItem.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
90. ClaimResponse.addItem.unitPrice
Definition

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

Control0..1
TypeMoney
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
91. ClaimResponse.addItem.factor
Definition

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

Control0..1
Typedecimal
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
92. ClaimResponse.addItem.net
Definition

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

Control0..1
TypeMoney
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
93. ClaimResponse.addItem.bodySite
Definition

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

Control0..1
BindingFor example codes, see OralSiteCodes The code for the teeth, quadrant, sextant and arch
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
94. ClaimResponse.addItem.subSite
Definition

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

Control0..*
BindingFor example codes, see SurfaceCodes The code for the tooth surface and surface combinations
TypeCodeableConcept
Requirements

Allows insurer to validate specific procedures.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
95. ClaimResponse.addItem.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
96. ClaimResponse.addItem.adjudication
Definition

The adjudication results.

Control1..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
97. ClaimResponse.addItem.detail
Definition

The second-tier service adjudications for payor added services.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
98. ClaimResponse.addItem.detail.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
99. ClaimResponse.addItem.detail.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
100. ClaimResponse.addItem.detail.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
101. ClaimResponse.addItem.detail.productOrService
Definition

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

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
102. ClaimResponse.addItem.detail.modifier
Definition

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

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
103. ClaimResponse.addItem.detail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
104. ClaimResponse.addItem.detail.unitPrice
Definition

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

Control0..1
TypeMoney
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
105. ClaimResponse.addItem.detail.factor
Definition

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

Control0..1
Typedecimal
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
106. ClaimResponse.addItem.detail.net
Definition

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

Control0..1
TypeMoney
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
107. ClaimResponse.addItem.detail.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
108. ClaimResponse.addItem.detail.adjudication
Definition

The adjudication results.

Control1..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
109. ClaimResponse.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

Control0..*
TypeBackboneElement
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
110. ClaimResponse.addItem.detail.subDetail.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
111. ClaimResponse.addItem.detail.subDetail.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
112. ClaimResponse.addItem.detail.subDetail.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
113. ClaimResponse.addItem.detail.subDetail.productOrService
Definition

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

Control1..1
BindingFor example codes, see USCLSCodes Allowable service and product codes
TypeCodeableConcept
Requirements

Necessary to state what was provided or done.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
114. ClaimResponse.addItem.detail.subDetail.modifier
Definition

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

Control0..*
BindingFor example codes, see ModifierTypeCodes Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
115. ClaimResponse.addItem.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

Control0..1
TypeQuantity(SimpleQuantity)
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
116. ClaimResponse.addItem.detail.subDetail.unitPrice
Definition

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

Control0..1
TypeMoney
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
117. ClaimResponse.addItem.detail.subDetail.factor
Definition

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

Control0..1
Typedecimal
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
118. ClaimResponse.addItem.detail.subDetail.net
Definition

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

Control0..1
TypeMoney
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
119. ClaimResponse.addItem.detail.subDetail.noteNumber
Definition

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

Control0..*
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
120. ClaimResponse.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

Control1..*
TypeSee ttp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
121. ClaimResponse.adjudication
Definition

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

Control0..*
TypeBackboneElement
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
122. ClaimResponse.adjudication.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
123. ClaimResponse.adjudication.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.adjudication.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
124. ClaimResponse.adjudication.extension:adjudicationDate
SliceNameadjudicationDate
Definition

Date on which the payment status of the claim was adjudicated

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(AdjudicationDate) (Extension Type: date)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
125. ClaimResponse.adjudication.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
126. ClaimResponse.adjudication.category
Definition

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

Control1..1
BindingFor example codes, see AdjudicationValueCodes The adjudication codes
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
127. ClaimResponse.adjudication.reason
Definition

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

Control0..1
BindingFor example codes, see AdjudicationReasonCodes The adjudication reason codes
TypeCodeableConcept
Requirements

To support understanding of variance from adjudication expectations.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
128. ClaimResponse.adjudication.amount
Definition

Monetary amount associated with the category.

Control0..1
TypeMoney
Requirements

Most adjuciation categories convey a monetary amount.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
129. ClaimResponse.adjudication.value
Definition

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

Control0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
130. ClaimResponse.total
Definition

Categorized monetary totals for the adjudication.

Control0..*
TypeBackboneElement
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
131. ClaimResponse.total.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
132. ClaimResponse.total.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
133. ClaimResponse.total.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
134. ClaimResponse.total.category
Definition

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

Control1..1
BindingFor example codes, see AdjudicationValueCodes The adjudication codes
TypeCodeableConcept
Requirements

Needed to convey the type of total provided.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
135. ClaimResponse.total.amount
Definition

Monetary total amount associated with the category.

Control1..1
TypeMoney
Requirements

Needed to convey the total monetary amount.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
136. ClaimResponse.payment
Definition

Payment details for the adjudication of the claim.

Control0..1
TypeBackboneElement
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
137. ClaimResponse.payment.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
138. ClaimResponse.payment.extension
Definition

An Extension

Control0..*
TypeExtension
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.payment.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
  • value @ url
139. ClaimResponse.payment.extension:claimAdjustmentType
SliceNameclaimAdjustmentType
Definition

The code for the type of adjustment for the claim

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(ClaimAdjustmentType) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
140. ClaimResponse.payment.extension:dispositionReason
SliceNamedispositionReason
Definition

Customer-specific code for the disposition reason, as related to how the claim was paid

Control0..* This element is affected by the following invariants: ele-1
TypeExtension(DispositionReason) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
141. ClaimResponse.payment.extension:reimburseType
SliceNamereimburseType
Definition

Method of payment code for the claim

Control0..1 This element is affected by the following invariants: ele-1
TypeExtension(ReimburseType) (Extension Type: CodeableConcept)
InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
142. ClaimResponse.payment.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
143. ClaimResponse.payment.type
Definition

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

Control1..1
BindingFor example codes, see ExamplePaymentTypeCodes The type (partial, complete) of the payment
TypeCodeableConcept
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
144. ClaimResponse.payment.adjustment
Definition

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

Control0..1
TypeMoney
Requirements

To advise the requestor of adjustments applied to the payment.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
145. ClaimResponse.payment.adjustmentReason
Definition

Reason for the payment adjustment.

Control0..1
BindingFor example codes, see PaymentAdjustmentReasonCodes Payment Adjustment reason codes
TypeCodeableConcept
Requirements

Needed to clarify the monetary adjustment.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
146. ClaimResponse.payment.date
Definition

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

Control0..1
Typedate
Requirements

To advise the payee when payment can be expected.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
147. ClaimResponse.payment.amount
Definition

Benefits payable less any payment adjustment.

Control1..1
TypeMoney
Requirements

Needed to provide the actual payment amount.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
148. ClaimResponse.payment.identifier
Definition

Issuer's unique identifier for the payment instrument.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Requirements

Enable the receiver to reconcile when payment received.

Comments

For example: EFT number or check number.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
149. ClaimResponse.fundsReserve
Definition

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

Control0..1
BindingFor example codes, see Funds Reservation Codes For whom funds are to be reserved: (Patient, Provider, None)
TypeCodeableConcept
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
150. ClaimResponse.formCode
Definition

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

Control0..1
BindingFor example codes, see Form Codes The forms codes
TypeCodeableConcept
Requirements

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

Comments

May be needed to identify specific jurisdictional forms.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
151. ClaimResponse.form
Definition

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

Control0..1
TypeAttachment
Requirements

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

Comments

Needed to permit insurers to include the actual form.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
152. ClaimResponse.processNote
Definition

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

Control0..*
TypeBackboneElement
Requirements

Provides the insurer specific textual explanations associated with the processing.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
153. ClaimResponse.processNote.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
154. ClaimResponse.processNote.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
155. ClaimResponse.processNote.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
156. ClaimResponse.processNote.number
Definition

A number to uniquely identify a note entry.

Control0..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link from adjudications.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
157. ClaimResponse.processNote.type
Definition

The business purpose of the note text.

Control0..1
BindingThe codes SHALL be taken from NoteType The presentation types of notes
Typecode
Requirements

To convey the expectation for when the text is used.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
158. ClaimResponse.processNote.text
Definition

The explanation or description associated with the processing.

Control1..1
Typestring
Requirements

Required to provide human readable explanation.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
159. ClaimResponse.processNote.language
Definition

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

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages A human language
Additional BindingsPurpose
AllLanguagesMax Binding
TypeCodeableConcept
Requirements

Note text may vary from the resource defined language.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
160. ClaimResponse.communicationRequest
Definition

Request for additional supporting or authorizing information.

Control0..*
TypeReference(CommunicationRequest))
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
161. ClaimResponse.insurance
Definition

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

Control0..*
TypeBackboneElement
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
162. ClaimResponse.insurance.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
163. ClaimResponse.insurance.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
164. ClaimResponse.insurance.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
165. ClaimResponse.insurance.sequence
Definition

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

Control1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
166. ClaimResponse.insurance.focal
Definition

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

Control1..1
Typeboolean
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
167. ClaimResponse.insurance.coverage
Definition

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

Control1..1
TypeReference(Coverage))
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
168. ClaimResponse.insurance.businessArrangement
Definition

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

Control0..1
Typestring
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
169. ClaimResponse.insurance.claimResponse
Definition

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

Control0..1
TypeReference(ClaimResponse))
Requirements

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

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
170. ClaimResponse.error
Definition

Errors encountered during the processing of the adjudication.

Control0..*
TypeBackboneElement
Requirements

Need to communicate processing issues to the requestor.

Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
171. ClaimResponse.error.id
Definition

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

Control0..1
Typestring
XML RepresentationIn the XML format, this property is represented as an attribute.
172. ClaimResponse.error.extension
Definition

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

Control0..*
TypeExtension
Alternate Namesextensionsuser content
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
173. ClaimResponse.error.modifierExtension
Definition

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

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

Control0..*
TypeExtension
Is Modifiertrue
Requirements

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

Alternate Namesextensionsuser contentmodifiers
Comments

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
174. ClaimResponse.error.itemSequence
Definition

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

Control0..1
TypepositiveInt
Requirements

Provides references to the claim items.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
175. ClaimResponse.error.detailSequence
Definition

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

Control0..1
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
176. ClaimResponse.error.subDetailSequence
Definition

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

Control0..1
TypepositiveInt
Requirements

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

InvariantsDefined on this element
ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
177. ClaimResponse.error.code
Definition

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

Control1..1
BindingFor example codes, see Adjudication Error Codes The adjudication error codes
TypeCodeableConcept
Requirements

Required to convey processing errors.

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