description: The QI Core ClaimResponse profile is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient.It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the ClaimResponse resource when using this profile
package_name: hl7.fhir.us.qicore
derivation: constraint
name: QICoreClaimResponse
type: ClaimResponse
elements:
  patient:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: The recipient of the products and services
    index: 3
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient']
    type: Reference
    mustSupport: true
    base: {max: '1', min: 1, path: ClaimResponse.patient}
    isSummary: true
  requestor:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: Party responsible for the claim
    index: 6
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization', 'http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner', 'http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole']
    type: Reference
    mustSupport: true
    base: {max: '1', min: 0, path: ClaimResponse.requestor}
    isSummary: false
  request:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: Id of resource triggering adjudication
    index: 7
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim']
    type: Reference
    mustSupport: true
    base: {max: '1', min: 0, path: ClaimResponse.request}
    isSummary: true
  use:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: claim | preauthorization | predetermination
    index: 2
    type: code
    mustSupport: true
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    base: {max: '1', min: 1, path: ClaimResponse.use}
    isSummary: true
    pattern: {type: Code, value: preauthorization}
  item:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: Adjudication for claim line items
    index: 8
    type: BackboneElement
    mustSupport: true
    array: true
    elements:
      adjudication:
        constraint:
          ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
        min: 1
        isModifier: false
        short: Adjudication details
        index: 9
        type: BackboneElement
        mustSupport: true
        array: true
        elements:
          category:
            constraint:
              ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
            isModifier: false
            short: This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
            index: 10
            type: CodeableConcept
            mustSupport: true
            base: {max: '1', min: 1, path: ClaimResponse.item.adjudication.category}
            isSummary: false
            pattern:
              type: CodeableConcept
              value:
                coding:
                - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
          amount:
            constraint:
              ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
            isModifier: false
            short: Monetary amount
            type: Money
            mustSupport: true
            base: {max: '1', min: 0, path: ClaimResponse.item.adjudication.amount}
            isSummary: false
            index: 11
        base: {max: '*', min: 1, path: ClaimResponse.item.adjudication}
        required: [category]
        isSummary: false
      detail:
        elements:
          detailSequence:
            constraint:
              ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
            isModifier: false
            short: Claim detail instance identifier
            index: 12
            type: positiveInt
            mustSupport: true
            base: {max: '1', min: 1, path: ClaimResponse.item.detail.detailSequence}
            isSummary: false
        required: [detailSequence]
    base: {max: '*', min: 0, path: ClaimResponse.item}
    required: [adjudication]
    isSummary: false
  type:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: More granular claim type
    index: 1
    type: CodeableConcept
    mustSupport: true
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    base: {max: '1', min: 1, path: ClaimResponse.type}
    isSummary: true
  created:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: Response creation date
    index: 4
    type: dateTime
    mustSupport: true
    base: {max: '1', min: 1, path: ClaimResponse.created}
    isSummary: true
  insurer:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: false
    short: Party responsible for reimbursement
    index: 5
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization']
    type: Reference
    mustSupport: true
    base: {max: '1', min: 1, path: ClaimResponse.insurer}
    isSummary: true
  status:
    constraint:
      ele-1: {human: All FHIR elements must have a @value or children, source: 'http://hl7.org/fhir/StructureDefinition/Element', severity: error, expression: hasValue() or (children().count() > id.count())}
    isModifier: true
    short: active | cancelled | draft | entered-in-error
    index: 0
    type: code
    mustSupport: true
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    base: {max: '1', min: 1, path: ClaimResponse.status}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    pattern: {type: Code, value: active}
package_version: 5.0.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse
base: http://hl7.org/fhir/StructureDefinition/ClaimResponse
version: 5.0.0-ballot
required: [created, insurer, status, type, patient, use]