{
"description": "This resource provides the adjudication details from the processing of a Claim resource.",
"_filename": "StructureDefinition-ClaimResponse.json",
"package_name": "hl7.fhir.r5.core",
"date": "2022-09-10T04:52:37+10:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2022-09-10T04:52:37.223+10:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "5.0.0-ballot",
"name": "ClaimResponse",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": false,
"type": "ClaimResponse",
"experimental": "false",
"resourceType": "StructureDefinition",
"title": null,
"package_version": "5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Financial.Billing"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "patient"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "fm"
} ],
"snapshot": {
"element": [ {
"constraint": [ {
"key": "dom-2",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"xpath": "not(parent::f:contained and f:contained)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-3",
"human": "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",
"xpath": "not(exists(for $contained in f:contained return $contained[not(exists(parent::*/descendant::f:reference/@value=concat('#', $contained/*/f:id/@value)) or exists(descendant::f:reference[@value='#']))]))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()"
}, {
"key": "dom-4",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-5",
"human": "If a resource is contained in another resource, it SHALL NOT have a security label",
"xpath": "not(exists(f:contained/*/f:meta/f:security))",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "error",
"expression": "contained.meta.security.empty()"
}, {
"key": "dom-6",
"human": "A resource should have narrative for robust management",
"xpath": "exists(f:text/h:div)",
"source": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"severity": "warning",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean": true
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
} ],
"expression": "text.`div`.exists()"
} ],
"path": "ClaimResponse",
"min": 0,
"definition": "This resource provides the adjudication details from the processing of a Claim resource.",
"isModifier": false,
"short": "Response to a claim predetermination or preauthorization",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "Event",
"identity": "workflow"
}, {
"map": "financial.billing",
"identity": "w5"
} ],
"mustSupport": false,
"alias": [ "Remittance Advice" ],
"max": "*",
"id": "ClaimResponse",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse"
},
"isSummary": false
}, {
"path": "ClaimResponse.id",
"min": 0,
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"isModifier": false,
"short": "Logical id of this artifact",
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "id"
} ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.id",
"comment": "Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.",
"isModifier": false,
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.implicitRules",
"min": 0,
"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.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"type": [ {
"code": "uri"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.implicitRules",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"isModifier": false,
"short": "Language of the resource content",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "IETF language tag"
},
"max": "1",
"id": "ClaimResponse.language",
"comment": "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).",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.text",
"min": 0,
"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.",
"isModifier": false,
"short": "Text summary of the resource, for human interpretation",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"mustSupport": false,
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "ClaimResponse.text",
"comment": "Contained resources do not have a 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.",
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
},
"isSummary": false
}, {
"path": "ClaimResponse.contained",
"min": 0,
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.",
"isModifier": false,
"short": "Contained, inline Resources",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"mustSupport": false,
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "ClaimResponse.contained",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. 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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"mustSupport": false,
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.identifier",
"requirements": "Allows claim responses to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this claim response.",
"isModifier": false,
"short": "Business Identifier for a claim response",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.identifier",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.identifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.status",
"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'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimResponseStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "ClaimResponse.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"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
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.type",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 1,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim."
},
"max": "1",
"id": "ClaimResponse.type",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.type"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.subType",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 0,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode."
},
"max": "1",
"id": "ClaimResponse.subType",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.subType"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.use",
"requirements": "This element is required to understand the nature of the request for adjudication.",
"min": 1,
"definition": "A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.",
"isModifier": false,
"short": "claim | preauthorization | predetermination",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-use|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "Claim, preauthorization, predetermination."
},
"max": "1",
"id": "ClaimResponse.use",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.use"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.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.",
"min": 1,
"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.",
"isModifier": false,
"short": "The recipient of the products and services",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.patient",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.patient"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"definition": "The date this resource was created.",
"isModifier": false,
"short": "Response creation date",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.created",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.created"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurer",
"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.",
"min": 0,
"definition": "The party responsible for authorization, adjudication and reimbursement.",
"isModifier": false,
"short": "Party responsible for reimbursement",
"mapping": [ {
"map": "Event.performer",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurer",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.insurer"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.requestor",
"min": 0,
"definition": "The provider which is responsible for the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Party responsible for the claim",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.requestor",
"comment": "This party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.requestor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.request",
"min": 0,
"definition": "Original request resource reference.",
"isModifier": false,
"short": "Id of resource triggering adjudication",
"mapping": [ {
"map": "Event.basedOn",
"identity": "workflow"
}, {
"map": "FiveWs.why[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.request",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.request"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.outcome",
"requirements": "To advise the requestor of an overall processing outcome.",
"min": 1,
"definition": "The outcome of the claim, predetermination, or preauthorization processing.",
"isModifier": false,
"short": "queued | complete | error | partial",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
} ],
"description": "The result of the claim processing."
},
"max": "1",
"id": "ClaimResponse.outcome",
"comment": "The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.outcome"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ],
"description": "The overall result of the claim adjudication."
},
"max": "1",
"id": "ClaimResponse.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.decision"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.disposition",
"requirements": "Provided for user display.",
"min": 0,
"definition": "A human readable description of the status of the adjudication.",
"isModifier": false,
"short": "Disposition Message",
"mapping": [ {
"map": "Event.note",
"identity": "workflow"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.disposition",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.disposition"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.preAuthRef",
"requirements": "On subsequent claims, the insurer may require the provider to quote this value.",
"min": 0,
"definition": "Reference from the Insurer which is used in later communications which refers to this adjudication.",
"isModifier": false,
"short": "Preauthorization reference",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.preAuthRef",
"comment": "This value is only present on preauthorization adjudications.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.preAuthRef"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.preAuthPeriod",
"requirements": "To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.",
"min": 0,
"definition": "The time frame during which this authorization is effective.",
"isModifier": false,
"short": "Preauthorization reference effective period",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.preAuthPeriod",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.preAuthPeriod"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payeeType",
"requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.",
"min": 0,
"definition": "Type of Party to be reimbursed: subscriber, provider, other.",
"isModifier": false,
"short": "Party to be paid any benefits payable",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payeetype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A code for the party to be reimbursed."
},
"max": "1",
"id": "ClaimResponse.payeeType",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payeeType"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.encounter",
"requirements": "Used in some jurisdictions to link clinical events to claim items.",
"min": 0,
"definition": "The Encounters during which this Claim was created or to which the creation of this record is tightly associated.",
"isModifier": false,
"short": "Encounters related to this billed item",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.encounter",
"comment": "This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.encounter"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.diagnosisRelatedGroup",
"requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.",
"min": 0,
"definition": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.",
"isModifier": false,
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ]
},
"max": "1",
"id": "ClaimResponse.diagnosisRelatedGroup",
"comment": "For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.diagnosisRelatedGroup"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item",
"requirements": "The adjudication for items provided on the claim.",
"min": 0,
"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.",
"isModifier": false,
"short": "Adjudication for claim line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "ClaimResponse.item",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item"
},
"isSummary": false
}, {
"path": "ClaimResponse.item.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.itemSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim item.",
"min": 1,
"definition": "A number to uniquely reference the claim item entries.",
"isModifier": false,
"short": "Claim item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.itemSequence",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.item.itemSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.adjudication",
"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.",
"min": 0,
"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.",
"isModifier": false,
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"max": "*",
"id": "ClaimResponse.item.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.adjudication"
},
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.adjudication.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.adjudication.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.adjudication.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.adjudication.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.adjudication.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.adjudication.category",
"requirements": "Needed to enable understanding of the context of the other information in the adjudication.",
"min": 1,
"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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ClaimResponse.item.adjudication.category",
"comment": "For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.item.adjudication.category"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.adjudication.reason",
"requirements": "To support understanding of variance from adjudication expectations.",
"min": 0,
"definition": "A code supporting the understanding of the adjudication result and explaining variance from expected amount.",
"isModifier": false,
"short": "Explanation of adjudication outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
} ],
"description": "The adjudication reason codes."
},
"max": "1",
"id": "ClaimResponse.item.adjudication.reason",
"comment": "For example may indicate that the funds for this benefit type have been exhausted.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.reason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.adjudication.amount",
"requirements": "Most adjudication categories convey a monetary amount.",
"min": 0,
"definition": "Monetary amount associated with the category.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.adjudication.amount",
"comment": "For example: amount submitted, eligible amount, co-payment, and benefit payable.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.amount"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.adjudication.value",
"requirements": "Some adjudication categories convey a percentage or a fixed value.",
"min": 0,
"definition": "A non-monetary value associated with the category. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monetary value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.adjudication.value",
"comment": "For example: eligible percentage or co-payment percentage.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.value"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail",
"requirements": "The adjudication for details provided on the claim.",
"min": 0,
"definition": "A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Adjudication for claim details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail"
},
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.detail.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.detail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.detail.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.detail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.detailSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.",
"min": 1,
"definition": "A number to uniquely reference the claim detail entry.",
"isModifier": false,
"short": "Claim detail instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.detail.detailSequence",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.detailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.detail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.detail.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Detail level adjudication details",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.subDetail",
"requirements": "The adjudication for sub-details provided on the claim.",
"min": 0,
"definition": "A sub-detail adjudication of a simple product or service.",
"isModifier": false,
"short": "Adjudication for claim sub-details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail"
},
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.detail.subDetail.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.item.detail.subDetail.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.",
"min": 1,
"definition": "A number to uniquely reference the claim sub-detail entry.",
"isModifier": false,
"short": "Claim sub-detail instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.subDetail.subDetailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.subDetail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Subdetail level adjudication details",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem",
"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.",
"min": 0,
"definition": "The first-tier service adjudications for payor added product or service lines.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"id": "ClaimResponse.addItem",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem"
},
"isSummary": false
}, {
"path": "ClaimResponse.addItem.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.itemSequence",
"requirements": "Provides references to the claim items.",
"min": 0,
"definition": "Claim items which this service line is intended to replace.",
"isModifier": false,
"short": "Item sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.itemSequence",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.itemSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detailSequence",
"requirements": "Provides references to the claim details within the claim item.",
"min": 0,
"definition": "The sequence number of the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Detail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detailSequence",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.subdetailSequence",
"requirements": "Provides references to the claim sub-details within the claim detail.",
"min": 0,
"definition": "The sequence number of the sub-details within the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Subdetail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.subdetailSequence",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.subdetailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.provider",
"requirements": "Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.",
"min": 0,
"definition": "The providers who are authorized for the services rendered to the patient.",
"isModifier": false,
"short": "Authorized providers",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.provider",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.provider"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.productOrServiceEnd",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.productOrServiceEnd"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"mapping": [ {
"map": "24.H",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ClaimResponse.addItem.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.programCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"isModifier": false,
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
}, {
"map": "24.A",
"identity": "rim"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.serviced[x]",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.serviced[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"isModifier": false,
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
}, {
"map": "24.B",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place of service: pharmacy, school, prison, etc."
},
"max": "1",
"id": "ClaimResponse.addItem.location[x]",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.location[x]"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.tax",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.tax"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.bodySite",
"min": 0,
"definition": "Physical location where the service is performed or applies.",
"isModifier": false,
"short": "Anatomical location",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BodySite"
} ],
"max": "*",
"id": "ClaimResponse.addItem.bodySite",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.bodySite"
},
"isSummary": false
}, {
"path": "ClaimResponse.addItem.bodySite.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.bodySite.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.bodySite.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.bodySite.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.bodySite.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.bodySite.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.bodySite.site",
"requirements": "Allows insurer to validate specific procedures.",
"min": 1,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"isModifier": false,
"short": "Location",
"type": [ {
"code": "CodeableReference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/BodyStructure" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ]
},
"max": "*",
"id": "ClaimResponse.addItem.bodySite.site",
"comment": "For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"base": {
"max": "*",
"min": 1,
"path": "ClaimResponse.addItem.bodySite.site"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.bodySite.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"isModifier": false,
"short": "Sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ]
},
"max": "*",
"id": "ClaimResponse.addItem.bodySite.subSite",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.bodySite.subSite"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail",
"min": 0,
"definition": "The second-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetail"
} ],
"max": "*",
"id": "ClaimResponse.addItem.detail",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail"
},
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.detail.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.detail.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.productOrServiceEnd",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.productOrServiceEnd"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.detail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.tax",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.tax"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.detail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items detail adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail",
"min": 0,
"definition": "The third-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemSubDetail"
} ],
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail"
},
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.revenue",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.revenue"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.productOrService",
"comment": "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'.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.productOrService"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.productOrServiceEnd",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.productOrServiceEnd"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.modifier",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.modifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.quantity",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.quantity"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.unitPrice",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.unitPrice"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.factor"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.tax",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.tax"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.net"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.noteNumber",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.noteNumber"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.decision"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.addItem.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items detail adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.subDetail.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.adjudication",
"requirements": "Some insurers will receive line-items but provide the adjudication only at a summary or header-level.",
"min": 0,
"definition": "The adjudication results which are presented at the header level rather than at the line-item or add-item levels.",
"isModifier": false,
"short": "Header-level adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.adjudication",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.adjudication"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.total",
"requirements": "To provide the requestor with financial totals by category for the adjudication.",
"min": 0,
"definition": "Categorized monetary totals for the adjudication.",
"isModifier": false,
"short": "Adjudication totals",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Total"
} ],
"max": "*",
"id": "ClaimResponse.total",
"comment": "Totals for amounts submitted, co-pays, benefits payable etc.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.total"
},
"isSummary": true
}, {
"path": "ClaimResponse.total.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.total.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.total.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.total.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.total.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.total.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.total.category",
"requirements": "Needed to convey the type of total provided.",
"min": 1,
"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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ClaimResponse.total.category",
"comment": "For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.total.category"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.total.amount",
"requirements": "Needed to convey the total monetary amount.",
"min": 1,
"definition": "Monetary total amount associated with the category.",
"isModifier": false,
"short": "Financial total for the category",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.total.amount",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.total.amount"
},
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment",
"requirements": "Needed to convey references to the financial instrument that has been used if payment has been made.",
"min": 0,
"definition": "Payment details for the adjudication of the claim.",
"isModifier": false,
"short": "Payment Details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"max": "1",
"id": "ClaimResponse.payment",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payment"
},
"isSummary": false
}, {
"path": "ClaimResponse.payment.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.payment.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.payment.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.payment.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.payment.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.payment.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.type",
"requirements": "To advise the requestor when the insurer believes all payments to have been completed.",
"min": 1,
"definition": "Whether this represents partial or complete payment of the benefits payable.",
"isModifier": false,
"short": "Partial or complete payment",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-paymenttype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
} ],
"description": "The type (partial, complete) of the payment."
},
"max": "1",
"id": "ClaimResponse.payment.type",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.payment.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.adjustment",
"requirements": "To advise the requestor of adjustments applied to the payment.",
"min": 0,
"definition": "Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.",
"isModifier": false,
"short": "Payment adjustment for non-claim issues",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.adjustment",
"comment": "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.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustment"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.adjustmentReason",
"requirements": "Needed to clarify the monetary adjustment.",
"min": 0,
"definition": "Reason for the payment adjustment.",
"isModifier": false,
"short": "Explanation for the adjustment",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
} ],
"description": "Payment Adjustment reason codes."
},
"max": "1",
"id": "ClaimResponse.payment.adjustmentReason",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustmentReason"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.date",
"requirements": "To advise the payee when payment can be expected.",
"min": 0,
"definition": "Estimated date the payment will be issued or the actual issue date of payment.",
"isModifier": false,
"short": "Expected date of payment",
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.date",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.date"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.amount",
"requirements": "Needed to provide the actual payment amount.",
"min": 1,
"definition": "Benefits payable less any payment adjustment.",
"isModifier": false,
"short": "Payable amount after adjustment",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.amount",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.payment.amount"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.payment.identifier",
"requirements": "Enable the receiver to reconcile when payment received.",
"min": 0,
"definition": "Issuer's unique identifier for the payment instrument.",
"isModifier": false,
"short": "Business identifier for the payment",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.identifier",
"comment": "For example: EFT number or check number.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.identifier"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.fundsReserve",
"requirements": "Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.",
"min": 0,
"definition": "A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.",
"isModifier": false,
"short": "Funds reserved status",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "For whom funds are to be reserved: (Patient, Provider, None)."
},
"max": "1",
"id": "ClaimResponse.fundsReserve",
"comment": "Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.fundsReserve"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.formCode",
"requirements": "Needed to specify the specific form used for producing output for this response.",
"min": 0,
"definition": "A code for the form to be used for printing the content.",
"isModifier": false,
"short": "Printed form identifier",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/forms",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The forms codes."
},
"max": "1",
"id": "ClaimResponse.formCode",
"comment": "May be needed to identify specific jurisdictional forms.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.formCode"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.form",
"requirements": "Needed to include the specific form used for producing output for this response.",
"min": 0,
"definition": "The actual form, by reference or inclusion, for printing the content or an EOB.",
"isModifier": false,
"short": "Printed reference or actual form",
"type": [ {
"code": "Attachment"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.form",
"comment": "Needed to permit insurers to include the actual form.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.form"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.processNote",
"requirements": "Provides the insurer specific textual explanations associated with the processing.",
"min": 0,
"definition": "A note that describes or explains adjudication results in a human readable form.",
"isModifier": false,
"short": "Note concerning adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"max": "*",
"id": "ClaimResponse.processNote",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.processNote"
},
"isSummary": false
}, {
"path": "ClaimResponse.processNote.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.processNote.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.processNote.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.processNote.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.processNote.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.processNote.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.processNote.number",
"requirements": "Necessary to provide a mechanism to link from adjudications.",
"min": 0,
"definition": "A number to uniquely identify a note entry.",
"isModifier": false,
"short": "Note instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.processNote.number",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.processNote.number"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.processNote.type",
"requirements": "To convey the expectation for when the text is used.",
"min": 0,
"definition": "The business purpose of the note text.",
"isModifier": false,
"short": "display | print | printoper",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/note-type|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The presentation types of notes."
},
"max": "1",
"id": "ClaimResponse.processNote.type",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.processNote.type"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.processNote.text",
"requirements": "Required to provide human readable explanation.",
"min": 1,
"definition": "The explanation or description associated with the processing.",
"isModifier": false,
"short": "Note explanatory text",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.processNote.text",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.processNote.text"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.processNote.language",
"requirements": "Note text may vary from the resource defined language.",
"min": 0,
"definition": "A code to define the language used in the text of the note.",
"isModifier": false,
"short": "Language of the text",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "IETF language tag"
},
"max": "1",
"id": "ClaimResponse.processNote.language",
"comment": "Only required if the language is different from the resource language.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.processNote.language"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.communicationRequest",
"requirements": "Need to communicate insurer request for additional information required to support the adjudication.",
"min": 0,
"definition": "Request for additional supporting or authorizing information.",
"isModifier": false,
"short": "Request for additional information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CommunicationRequest" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.communicationRequest",
"comment": "For example: professional reports, documents, images, clinical resources, or accident reports.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.communicationRequest"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance",
"requirements": "At least one insurer is required for a claim to be a claim.",
"min": 0,
"definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"isModifier": false,
"short": "Patient insurance information",
"mapping": [ {
"map": "Coverage",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "ClaimResponse.insurance",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.insurance"
},
"isSummary": false
}, {
"path": "ClaimResponse.insurance.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.insurance.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.insurance.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.insurance.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.insurance.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance.sequence",
"requirements": "To maintain order of the coverages.",
"min": 1,
"definition": "A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.",
"isModifier": false,
"short": "Insurance instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.sequence",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.sequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance.focal",
"requirements": "To identify which coverage in the list is being used to adjudicate this claim.",
"min": 1,
"definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.",
"isModifier": false,
"short": "Coverage to be used for adjudication",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.focal",
"comment": "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.",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.focal"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"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.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.coverage",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.coverage"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance.businessArrangement",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min": 0,
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"isModifier": false,
"short": "Additional provider contract number",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.businessArrangement",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.insurance.businessArrangement"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.insurance.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.",
"min": 0,
"definition": "The result of the adjudication of the line items for the Coverage specified in this insurance.",
"isModifier": false,
"short": "Adjudication results",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.claimResponse",
"comment": "Must not be specified when 'focal=true' for this insurance.",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.insurance.claimResponse"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.error",
"requirements": "Need to communicate processing issues to the requestor.",
"min": 0,
"definition": "Errors encountered during the processing of the adjudication.",
"isModifier": false,
"short": "Processing errors",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
} ],
"max": "*",
"id": "ClaimResponse.error",
"comment": "If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.",
"base": {
"max": "*",
"min": 0,
"path": "ClaimResponse.error"
},
"isSummary": false
}, {
"path": "ClaimResponse.error.id",
"min": 0,
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"isModifier": false,
"short": "Unique id for inter-element referencing",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "http://hl7.org/fhirpath/System.String",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type",
"valueUrl": "string"
} ]
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.error.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.error.extension",
"min": 0,
"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.",
"isModifier": false,
"short": "Additional content defined by implementations",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.error.extension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
}, {
"key": "ext-1",
"human": "Must have either extensions or value[x], not both",
"xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), \"value\")])",
"source": "http://hl7.org/fhir/StructureDefinition/Extension",
"severity": "error",
"expression": "extension.exists() != value.exists()"
} ],
"path": "ClaimResponse.error.modifierExtension",
"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](extensibility.html#modifierExtension).",
"min": 0,
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"isModifier": true,
"short": "Extensions that cannot be ignored even if unrecognized",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.error.modifierExtension",
"comment": "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.",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary": true
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.error.itemSequence",
"requirements": "Provides references to the claim items.",
"min": 0,
"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.",
"isModifier": false,
"short": "Item sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.itemSequence",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.error.itemSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.error.detailSequence",
"requirements": "Provides references to the claim details within the claim item.",
"min": 0,
"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.",
"isModifier": false,
"short": "Detail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.detailSequence",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.error.detailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.error.subDetailSequence",
"requirements": "Provides references to the claim sub-details within the claim detail.",
"min": 0,
"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.",
"isModifier": false,
"short": "Subdetail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.subDetailSequence",
"base": {
"max": "1",
"min": 0,
"path": "ClaimResponse.error.subDetailSequence"
},
"isSummary": false
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "http://hl7.org/fhir/StructureDefinition/Element",
"severity": "error",
"expression": "hasValue() or (children().count() > id.count())"
} ],
"path": "ClaimResponse.error.code",
"requirements": "Required to convey processing errors.",
"min": 1,
"definition": "An error code, from a specified code system, which details why the claim could not be adjudicated.",
"isModifier": false,
"short": "Error code detailing processing issues",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication-error",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The adjudication error codes."
},
"max": "1",
"id": "ClaimResponse.error.code",
"base": {
"max": "1",
"min": 1,
"path": "ClaimResponse.error.code"
},
"isSummary": false
} ]
},
"status": "draft",
"id": "3a9eb2e2-e8a4-4c4e-9b3c-ad27f9013cb4",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
"version": "5.0.0-ballot",
"differential": {
"element": [ {
"path": "ClaimResponse",
"min": 0,
"definition": "This resource provides the adjudication details from the processing of a Claim resource.",
"isModifier": false,
"short": "Response to a claim predetermination or preauthorization",
"mapping": [ {
"map": "Event",
"identity": "workflow"
}, {
"map": "financial.billing",
"identity": "w5"
} ],
"mustSupport": false,
"alias": [ "Remittance Advice" ],
"max": "*",
"id": "ClaimResponse"
}, {
"path": "ClaimResponse.identifier",
"requirements": "Allows claim responses to be distinguished and referenced.",
"min": 0,
"definition": "A unique identifier assigned to this claim response.",
"isModifier": false,
"short": "Business Identifier for a claim response",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
} ],
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.identifier",
"isSummary": false
}, {
"path": "ClaimResponse.status",
"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'.",
"min": 1,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/fm-status|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimResponseStatus"
} ],
"description": "A code specifying the state of the resource instance."
},
"max": "1",
"id": "ClaimResponse.status",
"comment": "This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
"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
}, {
"path": "ClaimResponse.type",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 1,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-type",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimType"
} ],
"description": "The type or discipline-style of the claim."
},
"max": "1",
"id": "ClaimResponse.type",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
"isSummary": true
}, {
"path": "ClaimResponse.subType",
"requirements": "Some jurisdictions need a finer grained claim type for routing and adjudication.",
"min": 0,
"definition": "A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.",
"isModifier": false,
"short": "More granular claim type",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-subtype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ClaimSubType"
} ],
"description": "A more granular claim typecode."
},
"max": "1",
"id": "ClaimResponse.subType",
"comment": "This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
"isSummary": false
}, {
"path": "ClaimResponse.use",
"requirements": "This element is required to understand the nature of the request for adjudication.",
"min": 1,
"definition": "A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.",
"isModifier": false,
"short": "claim | preauthorization | predetermination",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-use|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Use"
} ],
"description": "Claim, preauthorization, predetermination."
},
"max": "1",
"id": "ClaimResponse.use",
"isSummary": true
}, {
"path": "ClaimResponse.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.",
"min": 1,
"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.",
"isModifier": false,
"short": "The recipient of the products and services",
"mapping": [ {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.patient",
"isSummary": true
}, {
"path": "ClaimResponse.created",
"requirements": "Need to record a timestamp for use by both the recipient and the issuer.",
"min": 1,
"definition": "The date this resource was created.",
"isModifier": false,
"short": "Response creation date",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
} ],
"type": [ {
"code": "dateTime"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.created",
"isSummary": true
}, {
"path": "ClaimResponse.insurer",
"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.",
"min": 0,
"definition": "The party responsible for authorization, adjudication and reimbursement.",
"isModifier": false,
"short": "Party responsible for reimbursement",
"mapping": [ {
"map": "Event.performer",
"identity": "workflow"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurer",
"isSummary": true
}, {
"path": "ClaimResponse.requestor",
"min": 0,
"definition": "The provider which is responsible for the claim, predetermination or preauthorization.",
"isModifier": false,
"short": "Party responsible for the claim",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.requestor",
"comment": "This party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner.",
"isSummary": false
}, {
"path": "ClaimResponse.request",
"min": 0,
"definition": "Original request resource reference.",
"isModifier": false,
"short": "Id of resource triggering adjudication",
"mapping": [ {
"map": "Event.basedOn",
"identity": "workflow"
}, {
"map": "FiveWs.why[x]",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Claim" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.request",
"isSummary": true
}, {
"path": "ClaimResponse.outcome",
"requirements": "To advise the requestor of an overall processing outcome.",
"min": 1,
"definition": "The outcome of the claim, predetermination, or preauthorization processing.",
"isModifier": false,
"short": "queued | complete | error | partial",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RemittanceOutcome"
} ],
"description": "The result of the claim processing."
},
"max": "1",
"id": "ClaimResponse.outcome",
"comment": "The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).",
"isSummary": true
}, {
"path": "ClaimResponse.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ],
"description": "The overall result of the claim adjudication."
},
"max": "1",
"id": "ClaimResponse.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": true
}, {
"path": "ClaimResponse.disposition",
"requirements": "Provided for user display.",
"min": 0,
"definition": "A human readable description of the status of the adjudication.",
"isModifier": false,
"short": "Disposition Message",
"mapping": [ {
"map": "Event.note",
"identity": "workflow"
} ],
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.disposition",
"isSummary": false
}, {
"path": "ClaimResponse.preAuthRef",
"requirements": "On subsequent claims, the insurer may require the provider to quote this value.",
"min": 0,
"definition": "Reference from the Insurer which is used in later communications which refers to this adjudication.",
"isModifier": false,
"short": "Preauthorization reference",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.preAuthRef",
"comment": "This value is only present on preauthorization adjudications.",
"isSummary": false
}, {
"path": "ClaimResponse.preAuthPeriod",
"requirements": "To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.",
"min": 0,
"definition": "The time frame during which this authorization is effective.",
"isModifier": false,
"short": "Preauthorization reference effective period",
"type": [ {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.preAuthPeriod",
"isSummary": false
}, {
"path": "ClaimResponse.payeeType",
"requirements": "Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.",
"min": 0,
"definition": "Type of Party to be reimbursed: subscriber, provider, other.",
"isModifier": false,
"short": "Party to be paid any benefits payable",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payeetype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PayeeType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "A code for the party to be reimbursed."
},
"max": "1",
"id": "ClaimResponse.payeeType",
"isSummary": false
}, {
"path": "ClaimResponse.encounter",
"requirements": "Used in some jurisdictions to link clinical events to claim items.",
"min": 0,
"definition": "The Encounters during which this Claim was created or to which the creation of this record is tightly associated.",
"isModifier": false,
"short": "Encounters related to this billed item",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.encounter",
"comment": "This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.",
"isSummary": false
}, {
"path": "ClaimResponse.diagnosisRelatedGroup",
"requirements": "Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.",
"min": 0,
"definition": "A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.",
"isModifier": false,
"short": "Package billing code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DiagnosisRelatedGroup"
} ]
},
"max": "1",
"id": "ClaimResponse.diagnosisRelatedGroup",
"comment": "For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.",
"isSummary": false
}, {
"path": "ClaimResponse.item",
"requirements": "The adjudication for items provided on the claim.",
"min": 0,
"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.",
"isModifier": false,
"short": "Adjudication for claim line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "ClaimResponse.item",
"isSummary": false
}, {
"path": "ClaimResponse.item.itemSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim item.",
"min": 1,
"definition": "A number to uniquely reference the claim item entries.",
"isModifier": false,
"short": "Claim item instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.itemSequence",
"isSummary": false
}, {
"path": "ClaimResponse.item.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.item.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication",
"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.",
"min": 0,
"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.",
"isModifier": false,
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"max": "*",
"id": "ClaimResponse.item.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication.category",
"requirements": "Needed to enable understanding of the context of the other information in the adjudication.",
"min": 1,
"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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ClaimResponse.item.adjudication.category",
"comment": "For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication.reason",
"requirements": "To support understanding of variance from adjudication expectations.",
"min": 0,
"definition": "A code supporting the understanding of the adjudication result and explaining variance from expected amount.",
"isModifier": false,
"short": "Explanation of adjudication outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationReason"
} ],
"description": "The adjudication reason codes."
},
"max": "1",
"id": "ClaimResponse.item.adjudication.reason",
"comment": "For example may indicate that the funds for this benefit type have been exhausted.",
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication.amount",
"requirements": "Most adjudication categories convey a monetary amount.",
"min": 0,
"definition": "Monetary amount associated with the category.",
"isModifier": false,
"short": "Monetary amount",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.adjudication.amount",
"comment": "For example: amount submitted, eligible amount, co-payment, and benefit payable.",
"isSummary": false
}, {
"path": "ClaimResponse.item.adjudication.value",
"requirements": "Some adjudication categories convey a percentage or a fixed value.",
"min": 0,
"definition": "A non-monetary value associated with the category. Mutually exclusive to the amount element above.",
"isModifier": false,
"short": "Non-monetary value",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.adjudication.value",
"comment": "For example: eligible percentage or co-payment percentage.",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail",
"requirements": "The adjudication for details provided on the claim.",
"min": 0,
"definition": "A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.",
"isModifier": false,
"short": "Adjudication for claim details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.detailSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.",
"min": 1,
"definition": "A number to uniquely reference the claim detail entry.",
"isModifier": false,
"short": "Claim detail instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.detail.detailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.detail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Detail level adjudication details",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail",
"requirements": "The adjudication for sub-details provided on the claim.",
"min": 0,
"definition": "A sub-detail adjudication of a simple product or service.",
"isModifier": false,
"short": "Adjudication for claim sub-details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"requirements": "Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.",
"min": 1,
"definition": "A number to uniquely reference the claim sub-detail entry.",
"isModifier": false,
"short": "Claim sub-detail instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.subDetailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Subdetail level adjudication details",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.addItem",
"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.",
"min": 0,
"definition": "The first-tier service adjudications for payor added product or service lines.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"id": "ClaimResponse.addItem",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.itemSequence",
"requirements": "Provides references to the claim items.",
"min": 0,
"definition": "Claim items which this service line is intended to replace.",
"isModifier": false,
"short": "Item sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.itemSequence",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detailSequence",
"requirements": "Provides references to the claim details within the claim item.",
"min": 0,
"definition": "The sequence number of the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Detail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.subdetailSequence",
"requirements": "Provides references to the claim sub-details within the claim detail.",
"min": 0,
"definition": "The sequence number of the sub-details within the details within the claim item which this line is intended to replace.",
"isModifier": false,
"short": "Subdetail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.subdetailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.provider",
"requirements": "Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.",
"min": 0,
"definition": "The providers who are authorized for the services rendered to the patient.",
"isModifier": false,
"short": "Authorized providers",
"mapping": [ {
"map": "FiveWs.source",
"identity": "w5"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.provider",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.revenue",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.productOrService",
"comment": "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'.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.productOrServiceEnd",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.modifier",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.programCode",
"requirements": "Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.",
"min": 0,
"definition": "Identifies the program under which this may be recovered.",
"isModifier": false,
"short": "Program the product or service is provided under",
"mapping": [ {
"map": "24.H",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-program-code",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ProgramCode"
} ],
"description": "Program specific reason codes."
},
"max": "*",
"id": "ClaimResponse.addItem.programCode",
"comment": "For example: Neonatal program, child dental program or drug users recovery program.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.serviced[x]",
"requirements": "Needed to determine whether the service or product was provided during the term of the insurance coverage.",
"min": 0,
"definition": "The date or dates when the service or product was supplied, performed or completed.",
"isModifier": false,
"short": "Date or dates of service or product delivery",
"mapping": [ {
"map": "FiveWs.done[x]",
"identity": "w5"
}, {
"map": "24.A",
"identity": "rim"
} ],
"type": [ {
"code": "date"
}, {
"code": "Period"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.serviced[x]",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.location[x]",
"requirements": "The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.",
"min": 0,
"definition": "Where the product or service was provided.",
"isModifier": false,
"short": "Place of service or where product was supplied",
"mapping": [ {
"map": "FiveWs.where[x]",
"identity": "w5"
}, {
"map": "24.B",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
}, {
"code": "Address"
}, {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Location" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-place",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServicePlace"
} ],
"description": "Place of service: pharmacy, school, prison, etc."
},
"max": "1",
"id": "ClaimResponse.addItem.location[x]",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.quantity",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.unitPrice",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.tax",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.bodySite",
"min": 0,
"definition": "Physical location where the service is performed or applies.",
"isModifier": false,
"short": "Anatomical location",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "BodySite"
} ],
"max": "*",
"id": "ClaimResponse.addItem.bodySite",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.bodySite.site",
"requirements": "Allows insurer to validate specific procedures.",
"min": 1,
"definition": "Physical service site on the patient (limb, tooth, etc.).",
"isModifier": false,
"short": "Location",
"type": [ {
"code": "CodeableReference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/BodyStructure" ]
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/tooth",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "OralSites"
} ]
},
"max": "*",
"id": "ClaimResponse.addItem.bodySite.site",
"comment": "For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.bodySite.subSite",
"requirements": "Allows insurer to validate specific procedures.",
"min": 0,
"definition": "A region or surface of the bodySite, e.g. limb region or tooth surface(s).",
"isModifier": false,
"short": "Sub-location",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/surface",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Surface"
} ]
},
"max": "*",
"id": "ClaimResponse.addItem.bodySite.subSite",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail",
"min": 0,
"definition": "The second-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemDetail"
} ],
"max": "*",
"id": "ClaimResponse.addItem.detail",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.revenue",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.productOrService",
"comment": "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'.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.productOrServiceEnd",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.detail.modifier",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.quantity",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.unitPrice",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.tax",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.detail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items detail adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail",
"min": 0,
"definition": "The third-tier service adjudications for payor added services.",
"isModifier": false,
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemSubDetail"
} ],
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.revenue",
"requirements": "Needed in the processing of institutional claims.",
"min": 0,
"definition": "The type of revenue or cost center providing the product and/or service.",
"isModifier": false,
"short": "Revenue or cost center code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-revenue-center",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "RevenueCenter"
} ],
"description": "Codes for the revenue or cost centers supplying the service and/or products."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.revenue",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.productOrService",
"requirements": "Necessary to state what was provided or done.",
"min": 0,
"definition": "When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.",
"isModifier": false,
"short": "Billing, service, product, or drug code",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ],
"description": "Allowable service and product codes."
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.productOrService",
"comment": "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'.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.productOrServiceEnd",
"min": 0,
"definition": "This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.",
"isModifier": false,
"short": "End of a range of codes",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/service-uscls",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ServiceProduct"
} ]
},
"alias": [ "End of a range of Drug Code; Bill Code; Service Cod" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.productOrServiceEnd",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.modifier",
"requirements": "To support inclusion of the item for adjudication or to charge an elevated fee.",
"min": 0,
"definition": "Item typification or modifiers codes to convey additional context for the product or service.",
"isModifier": false,
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-modifiers",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Modifiers"
} ],
"description": "Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen."
},
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.modifier",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.quantity",
"requirements": "Required when the product or service code does not convey the quantity provided.",
"min": 0,
"definition": "The number of repetitions of a service or product.",
"isModifier": false,
"short": "Count of products or services",
"mapping": [ {
"map": "24.G",
"identity": "rim"
} ],
"type": [ {
"code": "Quantity",
"profile": [ "http://hl7.org/fhir/StructureDefinition/SimpleQuantity" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.quantity",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.unitPrice",
"requirements": "The amount charged to the patient by the provider for a single unit.",
"min": 0,
"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.",
"isModifier": false,
"short": "Fee, charge or cost per item",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.unitPrice",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.factor",
"requirements": "When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.",
"min": 0,
"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.",
"isModifier": false,
"short": "Price scaling factor",
"type": [ {
"code": "decimal"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.factor",
"comment": "To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.tax",
"requirements": "Required when taxes are not embedded in the unit price or provided as a separate service.",
"min": 0,
"definition": "The total of taxes applicable for this product or service.",
"isModifier": false,
"short": "Total tax",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.tax",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.net",
"requirements": "Provides the total amount claimed for the group (if a grouper) or the line item.",
"min": 0,
"definition": "The quantity times the unit price for an additional service or product or charge.",
"isModifier": false,
"short": "Total item cost",
"mapping": [ {
"map": "24.F",
"identity": "rim"
} ],
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.net",
"comment": "For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.noteNumber",
"requirements": "Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.",
"min": 0,
"definition": "The numbers associated with notes below which apply to the adjudication of this item.",
"isModifier": false,
"short": "Applicable note numbers",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.noteNumber",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.decision",
"requirements": "To advise the requestor of the result of the adjudication process.",
"min": 0,
"definition": "The result of the claim, predetermination, or preauthorization adjudication.",
"isModifier": false,
"short": "Result of the adjudication",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/claim-decision|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationDecision"
} ]
},
"max": "1",
"id": "ClaimResponse.addItem.detail.subDetail.decision",
"comment": "The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amoutn will be paid (partial).",
"isSummary": false
}, {
"path": "ClaimResponse.addItem.detail.subDetail.adjudication",
"min": 0,
"definition": "The adjudication results.",
"isModifier": false,
"short": "Added items detail adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.addItem.detail.subDetail.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.adjudication",
"requirements": "Some insurers will receive line-items but provide the adjudication only at a summary or header-level.",
"min": 0,
"definition": "The adjudication results which are presented at the header level rather than at the line-item or add-item levels.",
"isModifier": false,
"short": "Header-level adjudication",
"contentReference": "#ClaimResponse.item.adjudication",
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.adjudication",
"isSummary": false
}, {
"path": "ClaimResponse.total",
"requirements": "To provide the requestor with financial totals by category for the adjudication.",
"min": 0,
"definition": "Categorized monetary totals for the adjudication.",
"isModifier": false,
"short": "Adjudication totals",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Total"
} ],
"max": "*",
"id": "ClaimResponse.total",
"comment": "Totals for amounts submitted, co-pays, benefits payable etc.",
"isSummary": true
}, {
"path": "ClaimResponse.total.category",
"requirements": "Needed to convey the type of total provided.",
"min": 1,
"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.",
"isModifier": false,
"short": "Type of adjudication information",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Adjudication"
} ],
"description": "The adjudication codes."
},
"max": "1",
"id": "ClaimResponse.total.category",
"comment": "For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.",
"isSummary": true
}, {
"path": "ClaimResponse.total.amount",
"requirements": "Needed to convey the total monetary amount.",
"min": 1,
"definition": "Monetary total amount associated with the category.",
"isModifier": false,
"short": "Financial total for the category",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.total.amount",
"isSummary": true
}, {
"path": "ClaimResponse.payment",
"requirements": "Needed to convey references to the financial instrument that has been used if payment has been made.",
"min": 0,
"definition": "Payment details for the adjudication of the claim.",
"isModifier": false,
"short": "Payment Details",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"max": "1",
"id": "ClaimResponse.payment",
"isSummary": false
}, {
"path": "ClaimResponse.payment.type",
"requirements": "To advise the requestor when the insurer believes all payments to have been completed.",
"min": 1,
"definition": "Whether this represents partial or complete payment of the benefits payable.",
"isModifier": false,
"short": "Partial or complete payment",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/ex-paymenttype",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentType"
} ],
"description": "The type (partial, complete) of the payment."
},
"max": "1",
"id": "ClaimResponse.payment.type",
"isSummary": false
}, {
"path": "ClaimResponse.payment.adjustment",
"requirements": "To advise the requestor of adjustments applied to the payment.",
"min": 0,
"definition": "Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.",
"isModifier": false,
"short": "Payment adjustment for non-claim issues",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.adjustment",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.payment.adjustmentReason",
"requirements": "Needed to clarify the monetary adjustment.",
"min": 0,
"definition": "Reason for the payment adjustment.",
"isModifier": false,
"short": "Explanation for the adjustment",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "PaymentAdjustmentReason"
} ],
"description": "Payment Adjustment reason codes."
},
"max": "1",
"id": "ClaimResponse.payment.adjustmentReason",
"isSummary": false
}, {
"path": "ClaimResponse.payment.date",
"requirements": "To advise the payee when payment can be expected.",
"min": 0,
"definition": "Estimated date the payment will be issued or the actual issue date of payment.",
"isModifier": false,
"short": "Expected date of payment",
"type": [ {
"code": "date"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.date",
"isSummary": false
}, {
"path": "ClaimResponse.payment.amount",
"requirements": "Needed to provide the actual payment amount.",
"min": 1,
"definition": "Benefits payable less any payment adjustment.",
"isModifier": false,
"short": "Payable amount after adjustment",
"type": [ {
"code": "Money"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.amount",
"isSummary": false
}, {
"path": "ClaimResponse.payment.identifier",
"requirements": "Enable the receiver to reconcile when payment received.",
"min": 0,
"definition": "Issuer's unique identifier for the payment instrument.",
"isModifier": false,
"short": "Business identifier for the payment",
"type": [ {
"code": "Identifier"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.payment.identifier",
"comment": "For example: EFT number or check number.",
"isSummary": false
}, {
"path": "ClaimResponse.fundsReserve",
"requirements": "Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.",
"min": 0,
"definition": "A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.",
"isModifier": false,
"short": "Funds reserved status",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/fundsreserve",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "FundsReserve"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "For whom funds are to be reserved: (Patient, Provider, None)."
},
"max": "1",
"id": "ClaimResponse.fundsReserve",
"comment": "Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.",
"isSummary": false
}, {
"path": "ClaimResponse.formCode",
"requirements": "Needed to specify the specific form used for producing output for this response.",
"min": 0,
"definition": "A code for the form to be used for printing the content.",
"isModifier": false,
"short": "Printed form identifier",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/forms",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Forms"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The forms codes."
},
"max": "1",
"id": "ClaimResponse.formCode",
"comment": "May be needed to identify specific jurisdictional forms.",
"isSummary": false
}, {
"path": "ClaimResponse.form",
"requirements": "Needed to include the specific form used for producing output for this response.",
"min": 0,
"definition": "The actual form, by reference or inclusion, for printing the content or an EOB.",
"isModifier": false,
"short": "Printed reference or actual form",
"type": [ {
"code": "Attachment"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.form",
"comment": "Needed to permit insurers to include the actual form.",
"isSummary": false
}, {
"path": "ClaimResponse.processNote",
"requirements": "Provides the insurer specific textual explanations associated with the processing.",
"min": 0,
"definition": "A note that describes or explains adjudication results in a human readable form.",
"isModifier": false,
"short": "Note concerning adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"max": "*",
"id": "ClaimResponse.processNote",
"isSummary": false
}, {
"path": "ClaimResponse.processNote.number",
"requirements": "Necessary to provide a mechanism to link from adjudications.",
"min": 0,
"definition": "A number to uniquely identify a note entry.",
"isModifier": false,
"short": "Note instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.processNote.number",
"isSummary": false
}, {
"path": "ClaimResponse.processNote.type",
"requirements": "To convey the expectation for when the text is used.",
"min": 0,
"definition": "The business purpose of the note text.",
"isModifier": false,
"short": "display | print | printoper",
"type": [ {
"code": "code"
} ],
"mustSupport": false,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/note-type|5.0.0-ballot",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "NoteType"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The presentation types of notes."
},
"max": "1",
"id": "ClaimResponse.processNote.type",
"isSummary": false
}, {
"path": "ClaimResponse.processNote.text",
"requirements": "Required to provide human readable explanation.",
"min": 1,
"definition": "The explanation or description associated with the processing.",
"isModifier": false,
"short": "Note explanatory text",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.processNote.text",
"isSummary": false
}, {
"path": "ClaimResponse.processNote.language",
"requirements": "Note text may vary from the resource defined language.",
"min": 0,
"definition": "A code to define the language used in the text of the note.",
"isModifier": false,
"short": "Language of the text",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/languages",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "Language"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "IETF language tag"
},
"max": "1",
"id": "ClaimResponse.processNote.language",
"comment": "Only required if the language is different from the resource language.",
"isSummary": false
}, {
"path": "ClaimResponse.communicationRequest",
"requirements": "Need to communicate insurer request for additional information required to support the adjudication.",
"min": 0,
"definition": "Request for additional supporting or authorizing information.",
"isModifier": false,
"short": "Request for additional information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/CommunicationRequest" ]
} ],
"mustSupport": false,
"max": "*",
"id": "ClaimResponse.communicationRequest",
"comment": "For example: professional reports, documents, images, clinical resources, or accident reports.",
"isSummary": false
}, {
"path": "ClaimResponse.insurance",
"requirements": "At least one insurer is required for a claim to be a claim.",
"min": 0,
"definition": "Financial instruments for reimbursement for the health care products and services specified on the claim.",
"isModifier": false,
"short": "Patient insurance information",
"mapping": [ {
"map": "Coverage",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "ClaimResponse.insurance",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.insurance.sequence",
"requirements": "To maintain order of the coverages.",
"min": 1,
"definition": "A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.",
"isModifier": false,
"short": "Insurance instance identifier",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.sequence",
"isSummary": false
}, {
"path": "ClaimResponse.insurance.focal",
"requirements": "To identify which coverage in the list is being used to adjudicate this claim.",
"min": 1,
"definition": "A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.",
"isModifier": false,
"short": "Coverage to be used for adjudication",
"type": [ {
"code": "boolean"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.focal",
"comment": "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.",
"isSummary": false
}, {
"path": "ClaimResponse.insurance.coverage",
"requirements": "Required to allow the adjudicator to locate the correct policy and history within their information system.",
"min": 1,
"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.",
"isModifier": false,
"short": "Insurance information",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Coverage" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.coverage",
"isSummary": false
}, {
"path": "ClaimResponse.insurance.businessArrangement",
"requirements": "Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.",
"min": 0,
"definition": "A business agreement number established between the provider and the insurer for special business processing purposes.",
"isModifier": false,
"short": "Additional provider contract number",
"type": [ {
"code": "string"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.businessArrangement",
"isSummary": false
}, {
"path": "ClaimResponse.insurance.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.",
"min": 0,
"definition": "The result of the adjudication of the line items for the Coverage specified in this insurance.",
"isModifier": false,
"short": "Adjudication results",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ClaimResponse" ]
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.insurance.claimResponse",
"comment": "Must not be specified when 'focal=true' for this insurance.",
"isSummary": false
}, {
"path": "ClaimResponse.error",
"requirements": "Need to communicate processing issues to the requestor.",
"min": 0,
"definition": "Errors encountered during the processing of the adjudication.",
"isModifier": false,
"short": "Processing errors",
"type": [ {
"code": "BackboneElement"
} ],
"mustSupport": false,
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
} ],
"max": "*",
"id": "ClaimResponse.error",
"comment": "If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.",
"isSummary": false
}, {
"path": "ClaimResponse.error.itemSequence",
"requirements": "Provides references to the claim items.",
"min": 0,
"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.",
"isModifier": false,
"short": "Item sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.itemSequence",
"isSummary": false
}, {
"path": "ClaimResponse.error.detailSequence",
"requirements": "Provides references to the claim details within the claim item.",
"min": 0,
"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.",
"isModifier": false,
"short": "Detail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.detailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.error.subDetailSequence",
"requirements": "Provides references to the claim sub-details within the claim detail.",
"min": 0,
"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.",
"isModifier": false,
"short": "Subdetail sequence number",
"type": [ {
"code": "positiveInt"
} ],
"mustSupport": false,
"max": "1",
"id": "ClaimResponse.error.subDetailSequence",
"isSummary": false
}, {
"path": "ClaimResponse.error.code",
"requirements": "Required to convey processing errors.",
"min": 1,
"definition": "An error code, from a specified code system, which details why the claim could not be adjudicated.",
"isModifier": false,
"short": "Error code detailing processing issues",
"type": [ {
"code": "CodeableConcept"
} ],
"mustSupport": false,
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/adjudication-error",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "AdjudicationError"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The adjudication error codes."
},
"max": "1",
"id": "ClaimResponse.error.code",
"isSummary": false
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/fm/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}