FHIR Implementation Guide for HCX
0.0.1 - CI Build

FHIR Implementation Guide for HCX - Local Development build (v0.0.1). See the Directory of published versions

Resource Profile: HCX Claim Response

Defining URL:http://hl7.org/fhir/StructureDefinition/HCXClaimResponse
Version:0.0.1
Name:ClaimResponse
Status:Draft as of 2019-11-01T09:29:23+11:00 (Standards Status: Trial Use)
Definition:

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

Publisher:HL7 International - HCX
Committee:Financial Management
Maturity:2
Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/HCXClaimResponse

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClaimResponse

Summary

Mandatory: 5 elements

Extensions

This structure refers to these extensions:

Maturity: 2

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseResponse to a claim predetermination or preauthorization
... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... StructureDefinition-HCXOrganizationExtension.html 0..*Reference(Organization)Additional content defined by implementations
URL: https://swasth-digital-health-foundation.github.io/standards/output/StructureDefinition-HCXOrganizationExtension.html
... identifier 1..1IdentifierBusiness Identifier for a claim response
... requestor 1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ1..1Reference(Claim)Id of resource triggering adjudication
... item
.... adjudication
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-claim-denial-codes.html (example): The adjudication reason codes.

... total Σ1..*BackboneElementAdjudication totals

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseResponse to a claim predetermination or preauthorization
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... StructureDefinition-HCXOrganizationExtension.html 0..*Reference(Organization)Additional content defined by implementations
URL: https://swasth-digital-health-foundation.github.io/standards/output/StructureDefinition-HCXOrganizationExtension.html
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..1IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ1..1Reference(Claim)Id of resource triggering adjudication
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdjudication details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-claim-denial-codes.html (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*See adjudication (ClaimResponse)Added items adjudication
.... detail 0..*BackboneElementInsurer added line details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ1..*BackboneElementAdjudication totals
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

This structure is derived from ClaimResponse

Summary

Mandatory: 5 elements

Extensions

This structure refers to these extensions:

Maturity: 2

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseResponse to a claim predetermination or preauthorization
... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... StructureDefinition-HCXOrganizationExtension.html 0..*Reference(Organization)Additional content defined by implementations
URL: https://swasth-digital-health-foundation.github.io/standards/output/StructureDefinition-HCXOrganizationExtension.html
... identifier 1..1IdentifierBusiness Identifier for a claim response
... requestor 1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ1..1Reference(Claim)Id of resource triggering adjudication
... item
.... adjudication
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-claim-denial-codes.html (example): The adjudication reason codes.

... total Σ1..*BackboneElementAdjudication totals

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponseResponse to a claim predetermination or preauthorization
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... StructureDefinition-HCXOrganizationExtension.html 0..*Reference(Organization)Additional content defined by implementations
URL: https://swasth-digital-health-foundation.github.io/standards/output/StructureDefinition-HCXOrganizationExtension.html
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 1..1IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 1..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ1..1Reference(Claim)Id of resource triggering adjudication
... outcome Σ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdjudication details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: https://swasth-digital-health-foundation.github.io/standards/output/ValueSet-claim-denial-codes.html (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*See adjudication (ClaimResponse)Added items adjudication
.... detail 0..*BackboneElementInsurer added line details
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ1..*BackboneElementAdjudication totals
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
ClaimResponse.languagepreferredCommonLanguages
Max Binding: AllLanguages
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredUse
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.item.adjudication.reasonexamplehttps://swasth-digital-health-foundation.github.io/standards/output/ValueSet-claim-denial-codes.html
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Max Binding: AllLanguages
ClaimResponse.error.codeexampleAdjudication Error Codes

Constraints

IdPathDetailsRequirements
dom-2ClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3ClaimResponseIf 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-4ClaimResponseIf 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-5ClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6ClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1ClaimResponse.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.extension:secondaryinsurerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.extension:secondaryinsurerMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.subTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.useAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.patientAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.createdAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.requestorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.requestAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.outcomeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.dispositionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.preAuthRefAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.preAuthPeriodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payeeTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.itemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.itemSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.adjudication.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.adjudication.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.adjudication.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.adjudication.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.adjudication.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.adjudication.reasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.adjudication.amountAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.adjudication.valueAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.detail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.detail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.detail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.detail.detailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.subDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.subDetail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.detail.subDetail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.detail.subDetail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.item.detail.subDetail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.item.detail.subDetail.subDetailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.subDetail.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.item.detail.subDetail.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.itemSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.subdetailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.providerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.productOrServiceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.modifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.programCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.serviced[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.location[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.quantityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.unitPriceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.factorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.netAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.bodySiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.subSiteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.detail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.detail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.detail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.detail.productOrServiceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.modifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.quantityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.unitPriceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.factorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.netAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetailAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.detail.subDetail.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.detail.subDetail.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.addItem.detail.subDetail.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.addItem.detail.subDetail.productOrServiceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.modifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.quantityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.unitPriceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.factorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.netAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.noteNumberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.addItem.detail.subDetail.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.adjudicationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.totalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.total.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.total.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.total.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.total.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.total.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.total.amountAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.paymentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.payment.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.payment.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.payment.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.payment.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.adjustmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.adjustmentReasonAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.dateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.amountAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.payment.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.fundsReserveAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.formCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.formAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNoteAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNote.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.processNote.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.processNote.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.processNote.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.processNote.numberAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNote.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNote.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.processNote.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.communicationRequestAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insuranceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurance.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.insurance.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.insurance.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.insurance.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.insurance.sequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurance.focalAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurance.coverageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurance.businessArrangementAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.insurance.claimResponseAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.errorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.error.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.error.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.error.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1ClaimResponse.error.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1ClaimResponse.error.itemSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.error.detailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.error.subDetailSequenceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1ClaimResponse.error.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())