description: The QI-Core ClaimResponse profile is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient. It identifies the mandatory core elements, extensions, vocabularies and value sets which **SHALL** be present in the ClaimResponse resource when using this profile
package_name: hl7.fhir.us.qicore
derivation: constraint
name: QICoreClaimResponse
type: ClaimResponse
elements:
  patient:
    isModifier: false
    short: (QI) The recipient of the products and services
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient']
    type: Reference
    base: {max: '1', min: 1, path: ClaimResponse.patient}
    isSummary: true
    index: 3
  requestor:
    isModifier: false
    short: (QI) Party responsible for the claim
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization', 'http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner', 'http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole']
    type: Reference
    base: {max: '1', min: 0, path: ClaimResponse.requestor}
    isSummary: false
    index: 6
  request:
    isModifier: false
    short: (QI) Id of resource triggering adjudication
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim']
    type: Reference
    base: {max: '1', min: 0, path: ClaimResponse.request}
    isSummary: true
    index: 7
  use:
    isModifier: false
    short: (QI) claim | preauthorization | predetermination
    index: 2
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/claim-use|4.0.1'}
    base: {max: '1', min: 1, path: ClaimResponse.use}
    isSummary: true
    pattern: {type: Code, value: preauthorization}
  item:
    isModifier: false
    short: (QI) Adjudication for claim line items
    index: 8
    type: BackboneElement
    array: true
    elements:
      adjudication:
        min: 1
        isModifier: false
        short: (QI) Adjudication details
        index: 9
        type: BackboneElement
        array: true
        elements:
          category:
            isModifier: false
            short: (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
            type: CodeableConcept
            pattern:
              type: CodeableConcept
              value:
                coding:
                - {code: submitted, system: 'http://terminology.hl7.org/CodeSystem/adjudication'}
            base: {max: '1', min: 1, path: ClaimResponse.item.adjudication.category}
            isSummary: false
            index: 10
          amount:
            isModifier: false
            short: (QI) Monetary amount
            type: Money
            base: {max: '1', min: 0, path: ClaimResponse.item.adjudication.amount}
            isSummary: false
            index: 11
        base: {max: '*', min: 1, path: ClaimResponse.item.adjudication}
        required: [category]
        isSummary: false
      detail:
        elements:
          detailSequence:
            isModifier: false
            short: (QI) Claim detail instance identifier
            type: positiveInt
            base: {max: '1', min: 1, path: ClaimResponse.item.detail.detailSequence}
            isSummary: false
            index: 12
        required: [detailSequence]
    base: {max: '*', min: 0, path: ClaimResponse.item}
    required: [adjudication]
    isSummary: false
  type:
    isModifier: false
    short: (QI) More granular claim type
    type: CodeableConcept
    binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/claim-type'}
    base: {max: '1', min: 1, path: ClaimResponse.type}
    isSummary: true
    index: 1
  created:
    isModifier: false
    short: (QI) Response creation date
    type: dateTime
    base: {max: '1', min: 1, path: ClaimResponse.created}
    isSummary: true
    index: 4
  insurer:
    isModifier: false
    short: (QI) Party responsible for reimbursement
    refers: ['http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization']
    type: Reference
    base: {max: '1', min: 1, path: ClaimResponse.insurer}
    isSummary: true
    index: 5
  status:
    isModifier: true
    short: (QI) active | cancelled | draft | entered-in-error
    index: 0
    type: code
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/fm-status|4.0.1'}
    base: {max: '1', min: 1, path: ClaimResponse.status}
    isModifierReason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    isSummary: true
    pattern: {type: Code, value: active}
package_version: 7.0.0-ballot
class: profile
kind: resource
url: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse
base: http://hl7.org/fhir/StructureDefinition/ClaimResponse
version: 7.0.0-ballot
required: [created, insurer, status, type, patient, use]