{
"description": "Base StructureDefinition for ClaimResponse Resource",
"_filename": "claimresponse.profile.json",
"package_name": "hl7.fhir.core",
"date": "2016-12-06T12:22:34+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2016-12-06T12:22:34.981+11:00"
},
"publisher": "Health Level Seven International (Financial Management)",
"fhirVersion": "1.8.0",
"name": "ClaimResponse",
"mapping": [ {
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping",
"identity": "w5"
}, {
"uri": "http://www.cda-adc.ca/en/services/cdanet/",
"name": "Canadian Dental Association eclaims standard",
"identity": "cdanetv4"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
} ],
"abstract": false,
"type": "ClaimResponse",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "1.8.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 1
}, {
"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": "DomainResource",
"severity": "error",
"expression": "contained.contained.empty()"
}, {
"key": "dom-1",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"xpath": "not(parent::f:contained and f:text)",
"source": "DomainResource",
"severity": "error",
"expression": "contained.text.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": "DomainResource",
"severity": "error",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()"
}, {
"key": "dom-3",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))",
"source": "DomainResource",
"severity": "error",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()"
} ],
"path": "ClaimResponse",
"min": 0,
"definition": "This resource provides the adjudication details from the processing of a Claim resource.",
"short": "Remittance resource",
"mapping": [ {
"map": "Entity. Role, or Act",
"identity": "rim"
}, {
"map": "financial.billing",
"identity": "w5"
} ],
"alias": [ "Remittance Advice" ],
"max": "*",
"id": "ClaimResponse"
}, {
"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.",
"short": "Logical id of this artifact",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"type": [ {
"code": "id"
} ],
"max": "1",
"id": "ClaimResponse.id",
"base": {
"max": "1",
"min": 0,
"path": "Resource.id"
},
"isSummary": true
}, {
"path": "ClaimResponse.meta",
"min": 0,
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"short": "Metadata about the resource",
"type": [ {
"code": "Meta"
} ],
"max": "1",
"id": "ClaimResponse.meta",
"base": {
"max": "1",
"min": 0,
"path": "Resource.meta"
},
"isSummary": true
}, {
"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.",
"isModifier": true,
"short": "A set of rules under which this content was created",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"type": [ {
"code": "uri"
} ],
"max": "1",
"id": "ClaimResponse.implicitRules",
"base": {
"max": "1",
"min": 0,
"path": "Resource.implicitRules"
},
"isSummary": true
}, {
"path": "ClaimResponse.language",
"min": 0,
"definition": "The base language in which the resource is written.",
"short": "Language of the resource content",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"max": "1",
"id": "ClaimResponse.language",
"base": {
"max": "1",
"min": 0,
"path": "Resource.language"
}
}, {
"path": "ClaimResponse.text",
"min": 0,
"definition": "A human-readable narrative that contains a summary of the resource, and may 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.",
"short": "Text summary of the resource, for human interpretation",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"mapping": [ {
"map": "Act.text?",
"identity": "rim"
} ],
"type": [ {
"code": "Narrative"
} ],
"alias": [ "narrative", "html", "xhtml", "display" ],
"max": "1",
"id": "ClaimResponse.text",
"condition": [ "dom-1" ],
"base": {
"max": "1",
"min": 0,
"path": "DomainResource.text"
}
}, {
"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, and nor can they have their own independent transaction scope.",
"short": "Contained, inline Resources",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Resource"
} ],
"alias": [ "inline resources", "anonymous resources", "contained resources" ],
"max": "*",
"id": "ClaimResponse.contained",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.contained"
}
}, {
"path": "ClaimResponse.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.extension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.extension"
}
}, {
"path": "ClaimResponse.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. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "DomainResource.modifierExtension"
}
}, {
"id": "ClaimResponse.identifier",
"max": "*",
"min": 0,
"path": "ClaimResponse.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Response number",
"mapping": [ {
"map": "id",
"identity": "w5"
} ],
"definition": "The Response business identifier."
}, {
"path": "ClaimResponse.status",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"max": "1",
"id": "ClaimResponse.status",
"isSummary": true
}, {
"id": "ClaimResponse.created",
"max": "1",
"min": 0,
"path": "ClaimResponse.created",
"type": [ {
"code": "dateTime"
} ],
"short": "Creation date",
"mapping": [ {
"map": "when.recorded",
"identity": "w5"
} ],
"definition": "The date when the enclosed suite of services were performed or completed."
}, {
"id": "ClaimResponse.insurer",
"max": "1",
"min": 0,
"path": "ClaimResponse.insurer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Insurer",
"definition": "The Insurer who produced this adjudicated response."
}, {
"id": "ClaimResponse.requestProvider",
"max": "1",
"min": 0,
"path": "ClaimResponse.requestProvider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Responsible practitioner",
"mapping": [ {
"map": "B01",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The practitioner who is responsible for the services rendered to the patient."
}, {
"id": "ClaimResponse.requestOrganization",
"max": "1",
"min": 0,
"path": "ClaimResponse.requestOrganization",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Responsible organization",
"mapping": [ {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The organization which is responsible for the services rendered to the patient."
}, {
"id": "ClaimResponse.request",
"max": "1",
"min": 0,
"path": "ClaimResponse.request",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Id of resource triggering adjudication",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
}, {
"map": "why",
"identity": "w5"
} ],
"definition": "Original request resource referrence."
}, {
"id": "ClaimResponse.outcome",
"max": "1",
"min": 0,
"path": "ClaimResponse.outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "complete | error | partial",
"binding": {
"strength": "example",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
},
"definition": "Processing outcome errror, partial or complete processing."
}, {
"id": "ClaimResponse.disposition",
"max": "1",
"min": 0,
"path": "ClaimResponse.disposition",
"type": [ {
"code": "string"
} ],
"short": "Disposition Message",
"definition": "A description of the status of the adjudication."
}, {
"id": "ClaimResponse.payeeType",
"max": "1",
"min": 0,
"path": "ClaimResponse.payeeType",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Party to be paid any benefits payable",
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"definition": "Party to be reimbursed: Subscriber, provider, other."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.item",
"min": 0,
"definition": "The first tier service adjudications for submitted services.",
"short": "Line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"max": "*",
"id": "ClaimResponse.item"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.item.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.item.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.item.adjudication",
"min": 0,
"definition": "The adjudications results.",
"short": "Adjudication details",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"max": "*",
"id": "ClaimResponse.item.adjudication"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.adjudication.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.adjudication.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.item.adjudication.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.adjudication.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.item.adjudication.category",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.adjudication.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"definition": "Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc."
}, {
"id": "ClaimResponse.item.adjudication.reason",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.reason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication reason",
"binding": {
"strength": "extensible",
"description": "The adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"definition": "Adjudication reason such as limit reached."
}, {
"id": "ClaimResponse.item.adjudication.amount",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.amount",
"type": [ {
"code": "Money"
} ],
"short": "Monetary amount",
"definition": "Monetary amount associated with the code."
}, {
"id": "ClaimResponse.item.adjudication.value",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.value",
"type": [ {
"code": "decimal"
} ],
"short": "Non-monetary value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.item.detail",
"min": 0,
"definition": "The second tier service adjudications for submitted services.",
"short": "Detail line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.detail.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.item.detail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.detail.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.item.detail.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.item.detail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.adjudication",
"short": "Detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.item.detail.subDetail",
"min": 0,
"definition": "The third tier service adjudications for submitted services.",
"short": "Subdetail line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.item.detail.subDetail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.item.detail.subDetail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.item.detail.subDetail.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.item.detail.subDetail.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.subDetail.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"short": "Subdetail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.addItem",
"min": 0,
"definition": "The first tier service adjudications for payor added services.",
"short": "Insurer added line items",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"max": "*",
"id": "ClaimResponse.addItem"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.addItem.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.addItem.sequenceLinkId",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace."
}, {
"id": "ClaimResponse.addItem.revenue",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ClaimResponse.addItem.category",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"id": "ClaimResponse.addItem.service",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Group, Service or Product",
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied."
}, {
"path": "ClaimResponse.addItem.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ClaimResponse.addItem.modifier"
}, {
"id": "ClaimResponse.addItem.fee",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.."
}, {
"id": "ClaimResponse.addItem.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.addItem.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.addItem.detail",
"min": 0,
"definition": "The second tier service adjudications for payor added services.",
"short": "Added items details",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
"max": "*",
"id": "ClaimResponse.addItem.detail"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.addItem.detail.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.addItem.detail.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.addItem.detail.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.addItem.detail.revenue",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ClaimResponse.addItem.detail.category",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"id": "ClaimResponse.addItem.detail.service",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Service or Product",
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied."
}, {
"path": "ClaimResponse.addItem.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ClaimResponse.addItem.detail.modifier"
}, {
"id": "ClaimResponse.addItem.detail.fee",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.."
}, {
"id": "ClaimResponse.addItem.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.addItem.detail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.adjudication",
"short": "Added items detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.error",
"min": 0,
"definition": "Mutually exclusive with Services Provided (Item).",
"short": "Processing errors",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
} ],
"max": "*",
"id": "ClaimResponse.error"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.error.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.error.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.error.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.error.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.error.sequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Item sequence number",
"definition": "The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere."
}, {
"id": "ClaimResponse.error.detailSequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.detailSequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition."
}, {
"id": "ClaimResponse.error.subdetailSequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.subdetailSequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition."
}, {
"id": "ClaimResponse.error.code",
"max": "1",
"min": 1,
"path": "ClaimResponse.error.code",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Error code detailing processing issues",
"binding": {
"strength": "extensible",
"description": "The adjudication error codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
},
"definition": "An error code,from a specified code system, which details why the claim could not be adjudicated."
}, {
"id": "ClaimResponse.totalCost",
"max": "1",
"min": 0,
"path": "ClaimResponse.totalCost",
"type": [ {
"code": "Money"
} ],
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns."
}, {
"id": "ClaimResponse.unallocDeductable",
"max": "1",
"min": 0,
"path": "ClaimResponse.unallocDeductable",
"type": [ {
"code": "Money"
} ],
"short": "Unallocated deductible",
"definition": "The amount of deductible applied which was not allocated to any particular service line."
}, {
"id": "ClaimResponse.totalBenefit",
"max": "1",
"min": 0,
"path": "ClaimResponse.totalBenefit",
"type": [ {
"code": "Money"
} ],
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.payment",
"min": 0,
"definition": "Payment details for the claim if the claim has been paid.",
"short": "Payment details, if paid",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"max": "1",
"id": "ClaimResponse.payment"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.payment.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.payment.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.payment.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.payment.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.payment.type",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Partial or Complete",
"binding": {
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
},
"definition": "Whether this represents partial or complete payment of the claim."
}, {
"id": "ClaimResponse.payment.adjustment",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustment",
"type": [ {
"code": "Money"
} ],
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction."
}, {
"id": "ClaimResponse.payment.adjustmentReason",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustmentReason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Reason for Payment adjustment",
"binding": {
"strength": "extensible",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"definition": "Reason for the payment adjustment."
}, {
"id": "ClaimResponse.payment.date",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.date",
"type": [ {
"code": "date"
} ],
"short": "Expected data of Payment",
"definition": "Estimated payment data."
}, {
"id": "ClaimResponse.payment.amount",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.amount",
"type": [ {
"code": "Money"
} ],
"short": "Payment amount",
"definition": "Payable less any payment adjustment."
}, {
"id": "ClaimResponse.payment.identifier",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Payment identifier",
"definition": "Payment identifier."
}, {
"id": "ClaimResponse.reserved",
"max": "1",
"min": 0,
"path": "ClaimResponse.reserved",
"type": [ {
"code": "Coding"
} ],
"short": "Funds reserved status",
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
"definition": "Status of funds reservation (For provider, for Patient, None)."
}, {
"path": "ClaimResponse.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"id": "ClaimResponse.form"
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.note",
"min": 0,
"definition": "Note text.",
"short": "Processing notes",
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"max": "*",
"id": "ClaimResponse.note"
}, {
"path": "ClaimResponse.note.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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.note.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"path": "ClaimResponse.note.extension",
"min": 0,
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.note.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.note.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.note.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.note.number",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.number",
"type": [ {
"code": "positiveInt"
} ],
"short": "Note Number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item."
}, {
"id": "ClaimResponse.note.type",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "display | print | printoper",
"binding": {
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"definition": "The note purpose: Print/Display."
}, {
"id": "ClaimResponse.note.text",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.text",
"type": [ {
"code": "string"
} ],
"short": "Note explanatory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"definition": "The note text."
}, {
"id": "ClaimResponse.note.language",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.language",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Language",
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English."
}, {
"id": "ClaimResponse.communicationRequest",
"max": "*",
"min": 0,
"path": "ClaimResponse.communicationRequest",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
} ],
"short": "Request for additional information",
"definition": "Request for additional supporting or authorizing information, such as: documents, images or resources."
}, {
"constraint": [ {
"key": "ele-1",
"human": "All FHIR elements must have a @value or children",
"xpath": "@value|f:*|h:div",
"source": "Element",
"severity": "error",
"expression": "children().count() > id.count()"
} ],
"path": "ClaimResponse.insurance",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Financial instrument by which payment information for health care.",
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "ClaimResponse.insurance"
}, {
"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.",
"short": "xml:id (or equivalent in JSON)",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "string"
} ],
"representation": [ "xmlAttr" ],
"max": "1",
"id": "ClaimResponse.insurance.id",
"base": {
"max": "1",
"min": 0,
"path": "Element.id"
}
}, {
"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. In order 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.",
"short": "Additional Content defined by implementations",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "n/a",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content" ],
"max": "*",
"id": "ClaimResponse.insurance.extension",
"base": {
"max": "*",
"min": 0,
"path": "Element.extension"
}
}, {
"path": "ClaimResponse.insurance.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 that contains it. Usually modifier elements provide negation or qualification. In order 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.",
"isModifier": true,
"short": "Extensions that cannot be ignored",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"mapping": [ {
"map": "N/A",
"identity": "rim"
} ],
"type": [ {
"code": "Extension"
} ],
"alias": [ "extensions", "user content", "modifiers" ],
"max": "*",
"id": "ClaimResponse.insurance.modifierExtension",
"base": {
"max": "*",
"min": 0,
"path": "BackboneElement.modifierExtension"
},
"isSummary": true
}, {
"id": "ClaimResponse.insurance.sequence",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages."
}, {
"id": "ClaimResponse.insurance.focal",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.focal",
"type": [ {
"code": "boolean"
} ],
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated."
}, {
"id": "ClaimResponse.insurance.coverage",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
} ],
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
}, {
"id": "ClaimResponse.insurance.businessArrangement",
"max": "1",
"min": 0,
"path": "ClaimResponse.insurance.businessArrangement",
"type": [ {
"code": "string"
} ],
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions."
}, {
"path": "ClaimResponse.insurance.preAuthRef",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"definition": "A list of references from the Insurer to which these services pertain.",
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ClaimResponse.insurance.preAuthRef"
}, {
"path": "ClaimResponse.insurance.claimResponse",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"definition": "The Coverages adjudication details.",
"short": "Adjudication results",
"mapping": [ {
"map": "EOB",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
} ],
"max": "1",
"id": "ClaimResponse.insurance.claimResponse"
} ]
},
"status": "draft",
"id": "de886925-a07e-43a3-9090-95b51e8eda7c",
"kind": "resource",
"url": "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
"version": null,
"differential": {
"element": [ {
"id": "ClaimResponse",
"max": "*",
"min": 0,
"path": "ClaimResponse",
"alias": [ "Remittance Advice" ],
"short": "Remittance resource",
"mapping": [ {
"map": "financial.billing",
"identity": "w5"
} ],
"definition": "This resource provides the adjudication details from the processing of a Claim resource."
}, {
"id": "ClaimResponse.identifier",
"max": "*",
"min": 0,
"path": "ClaimResponse.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Response number",
"mapping": [ {
"map": "id",
"identity": "w5"
} ],
"definition": "The Response business identifier."
}, {
"path": "ClaimResponse.status",
"min": 0,
"definition": "The status of the resource instance.",
"isModifier": true,
"short": "active | cancelled | draft | entered-in-error",
"mapping": [ {
"map": "status",
"identity": "w5"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"description": "A code specifying the state of the resource instance.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fm-status"
}
},
"max": "1",
"id": "ClaimResponse.status",
"isSummary": true
}, {
"id": "ClaimResponse.created",
"max": "1",
"min": 0,
"path": "ClaimResponse.created",
"type": [ {
"code": "dateTime"
} ],
"short": "Creation date",
"mapping": [ {
"map": "when.recorded",
"identity": "w5"
} ],
"definition": "The date when the enclosed suite of services were performed or completed."
}, {
"id": "ClaimResponse.insurer",
"max": "1",
"min": 0,
"path": "ClaimResponse.insurer",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Insurer",
"definition": "The Insurer who produced this adjudicated response."
}, {
"id": "ClaimResponse.requestProvider",
"max": "1",
"min": 0,
"path": "ClaimResponse.requestProvider",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
} ],
"short": "Responsible practitioner",
"mapping": [ {
"map": "B01",
"identity": "cdanetv4"
}, {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The practitioner who is responsible for the services rendered to the patient."
}, {
"id": "ClaimResponse.requestOrganization",
"max": "1",
"min": 0,
"path": "ClaimResponse.requestOrganization",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Organization"
} ],
"short": "Responsible organization",
"mapping": [ {
"map": "who.source",
"identity": "w5"
} ],
"definition": "The organization which is responsible for the services rendered to the patient."
}, {
"id": "ClaimResponse.request",
"max": "1",
"min": 0,
"path": "ClaimResponse.request",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Claim"
} ],
"short": "Id of resource triggering adjudication",
"mapping": [ {
"map": "A02|G01",
"identity": "cdanetv4"
}, {
"map": "why",
"identity": "w5"
} ],
"definition": "Original request resource referrence."
}, {
"id": "ClaimResponse.outcome",
"max": "1",
"min": 0,
"path": "ClaimResponse.outcome",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "complete | error | partial",
"binding": {
"strength": "example",
"description": "The result of the claim processing",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/remittance-outcome"
}
},
"definition": "Processing outcome errror, partial or complete processing."
}, {
"id": "ClaimResponse.disposition",
"max": "1",
"min": 0,
"path": "ClaimResponse.disposition",
"type": [ {
"code": "string"
} ],
"short": "Disposition Message",
"definition": "A description of the status of the adjudication."
}, {
"id": "ClaimResponse.payeeType",
"max": "1",
"min": 0,
"path": "ClaimResponse.payeeType",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Party to be paid any benefits payable",
"binding": {
"strength": "example",
"description": "A code for the party to be reimbursed.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payeetype"
}
},
"definition": "Party to be reimbursed: Subscriber, provider, other."
}, {
"id": "ClaimResponse.item",
"max": "*",
"min": 0,
"path": "ClaimResponse.item",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Line items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Item"
} ],
"definition": "The first tier service adjudications for submitted services."
}, {
"id": "ClaimResponse.item.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.item.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.adjudication",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Adjudication details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Adjudication"
} ],
"definition": "The adjudications results."
}, {
"id": "ClaimResponse.item.adjudication.category",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.adjudication.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication category such as co-pay, eligible, benefit, etc.",
"binding": {
"strength": "extensible",
"description": "The adjudication codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication"
}
},
"definition": "Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc."
}, {
"id": "ClaimResponse.item.adjudication.reason",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.reason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Adjudication reason",
"binding": {
"strength": "extensible",
"description": "The adjudication reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-reason"
}
},
"definition": "Adjudication reason such as limit reached."
}, {
"id": "ClaimResponse.item.adjudication.amount",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.amount",
"type": [ {
"code": "Money"
} ],
"short": "Monetary amount",
"definition": "Monetary amount associated with the code."
}, {
"id": "ClaimResponse.item.adjudication.value",
"max": "1",
"min": 0,
"path": "ClaimResponse.item.adjudication.value",
"type": [ {
"code": "decimal"
} ],
"short": "Non-monetary value",
"definition": "A non-monetary value for example a percentage. Mutually exclusive to the amount element above."
}, {
"id": "ClaimResponse.item.detail",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Detail line items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "ItemDetail"
} ],
"definition": "The second tier service adjudications for submitted services."
}, {
"id": "ClaimResponse.item.detail.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.item.detail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.adjudication",
"short": "Detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"id": "ClaimResponse.item.detail.subDetail",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Subdetail line items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "SubDetail"
} ],
"definition": "The third tier service adjudications for submitted services."
}, {
"id": "ClaimResponse.item.detail.subDetail.sequenceLinkId",
"max": "1",
"min": 1,
"path": "ClaimResponse.item.detail.subDetail.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance",
"mapping": [ {
"map": "F07",
"identity": "cdanetv4"
} ],
"definition": "A service line number."
}, {
"id": "ClaimResponse.item.detail.subDetail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.item.detail.subDetail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.item.detail.subDetail.adjudication",
"short": "Subdetail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"id": "ClaimResponse.addItem",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Insurer added line items",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItem"
} ],
"definition": "The first tier service adjudications for payor added services."
}, {
"id": "ClaimResponse.addItem.sequenceLinkId",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instances",
"definition": "List of input service items which this service line is intended to replace."
}, {
"id": "ClaimResponse.addItem.revenue",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ClaimResponse.addItem.category",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"id": "ClaimResponse.addItem.service",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Group, Service or Product",
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied."
}, {
"path": "ClaimResponse.addItem.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ClaimResponse.addItem.modifier"
}, {
"id": "ClaimResponse.addItem.fee",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.."
}, {
"id": "ClaimResponse.addItem.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.addItem.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.adjudication",
"short": "Added items adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"id": "ClaimResponse.addItem.detail",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Added items details",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "AddedItemsDetail"
} ],
"definition": "The second tier service adjudications for payor added services."
}, {
"id": "ClaimResponse.addItem.detail.revenue",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.revenue",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Revenue or cost center code",
"binding": {
"strength": "example",
"description": "Codes for the revenue or cost centers supplying the service and/or products.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-revenue-center"
}
},
"definition": "The type of reveneu or cost center providing the product and/or service."
}, {
"id": "ClaimResponse.addItem.detail.category",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.category",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Type of service or product",
"binding": {
"strength": "example",
"description": "Benefit subcategories such as: oral-basic, major, glasses",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/benefit-subcategory"
}
},
"definition": "Health Care Service Type Codes to identify the classification of service or benefits."
}, {
"id": "ClaimResponse.addItem.detail.service",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.service",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Service or Product",
"binding": {
"strength": "example",
"description": "Allowable service and product codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/service-uscls"
}
},
"definition": "A code to indicate the Professional Service or Product supplied."
}, {
"path": "ClaimResponse.addItem.detail.modifier",
"requirements": "May impact on adjudication.",
"min": 0,
"definition": "Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hours.",
"short": "Service/Product billing modifiers",
"mapping": [ {
"map": "24.C, 24.D mods",
"identity": "rim"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"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.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/claim-modifiers"
}
},
"max": "*",
"id": "ClaimResponse.addItem.detail.modifier"
}, {
"id": "ClaimResponse.addItem.detail.fee",
"max": "1",
"min": 0,
"path": "ClaimResponse.addItem.detail.fee",
"type": [ {
"code": "Money"
} ],
"short": "Professional fee or Product charge",
"definition": "The fee charged for the professional service or product.."
}, {
"id": "ClaimResponse.addItem.detail.noteNumber",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.noteNumber",
"type": [ {
"code": "positiveInt"
} ],
"short": "List of note numbers which apply",
"definition": "A list of note references to the notes provided below."
}, {
"id": "ClaimResponse.addItem.detail.adjudication",
"max": "*",
"min": 0,
"path": "ClaimResponse.addItem.detail.adjudication",
"short": "Added items detail adjudication",
"definition": "The adjudications results.",
"contentReference": "#ClaimResponse.item.adjudication"
}, {
"id": "ClaimResponse.error",
"max": "*",
"min": 0,
"path": "ClaimResponse.error",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Processing errors",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Error"
} ],
"definition": "Mutually exclusive with Services Provided (Item)."
}, {
"id": "ClaimResponse.error.sequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.sequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Item sequence number",
"definition": "The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere."
}, {
"id": "ClaimResponse.error.detailSequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.detailSequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Detail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition."
}, {
"id": "ClaimResponse.error.subdetailSequenceLinkId",
"max": "1",
"min": 0,
"path": "ClaimResponse.error.subdetailSequenceLinkId",
"type": [ {
"code": "positiveInt"
} ],
"short": "Subdetail sequence number",
"definition": "The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an Addition."
}, {
"id": "ClaimResponse.error.code",
"max": "1",
"min": 1,
"path": "ClaimResponse.error.code",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Error code detailing processing issues",
"binding": {
"strength": "extensible",
"description": "The adjudication error codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/adjudication-error"
}
},
"definition": "An error code,from a specified code system, which details why the claim could not be adjudicated."
}, {
"id": "ClaimResponse.totalCost",
"max": "1",
"min": 0,
"path": "ClaimResponse.totalCost",
"type": [ {
"code": "Money"
} ],
"short": "Total Cost of service from the Claim",
"definition": "The total cost of the services reported.",
"requirements": "This is a check value that the receiver calculates and returns."
}, {
"id": "ClaimResponse.unallocDeductable",
"max": "1",
"min": 0,
"path": "ClaimResponse.unallocDeductable",
"type": [ {
"code": "Money"
} ],
"short": "Unallocated deductible",
"definition": "The amount of deductible applied which was not allocated to any particular service line."
}, {
"id": "ClaimResponse.totalBenefit",
"max": "1",
"min": 0,
"path": "ClaimResponse.totalBenefit",
"type": [ {
"code": "Money"
} ],
"short": "Total benefit payable for the Claim",
"definition": "Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)."
}, {
"id": "ClaimResponse.payment",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Payment details, if paid",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Payment"
} ],
"definition": "Payment details for the claim if the claim has been paid."
}, {
"id": "ClaimResponse.payment.type",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Partial or Complete",
"binding": {
"strength": "example",
"description": "The type (partial, complete) of the payment",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/ex-paymenttype"
}
},
"definition": "Whether this represents partial or complete payment of the claim."
}, {
"id": "ClaimResponse.payment.adjustment",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustment",
"type": [ {
"code": "Money"
} ],
"short": "Payment adjustment for non-Claim issues",
"definition": "Adjustment to the payment of this transaction which is not related to adjudication of this transaction."
}, {
"id": "ClaimResponse.payment.adjustmentReason",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.adjustmentReason",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Reason for Payment adjustment",
"binding": {
"strength": "extensible",
"description": "Payment Adjustment reason codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/payment-adjustment-reason"
}
},
"definition": "Reason for the payment adjustment."
}, {
"id": "ClaimResponse.payment.date",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.date",
"type": [ {
"code": "date"
} ],
"short": "Expected data of Payment",
"definition": "Estimated payment data."
}, {
"id": "ClaimResponse.payment.amount",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.amount",
"type": [ {
"code": "Money"
} ],
"short": "Payment amount",
"definition": "Payable less any payment adjustment."
}, {
"id": "ClaimResponse.payment.identifier",
"max": "1",
"min": 0,
"path": "ClaimResponse.payment.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Payment identifier",
"definition": "Payment identifier."
}, {
"id": "ClaimResponse.reserved",
"max": "1",
"min": 0,
"path": "ClaimResponse.reserved",
"type": [ {
"code": "Coding"
} ],
"short": "Funds reserved status",
"binding": {
"strength": "example",
"description": "For whom funds are to be reserved: (Patient, Provider, None).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/fundsreserve"
}
},
"definition": "Status of funds reservation (For provider, for Patient, None)."
}, {
"path": "ClaimResponse.form",
"min": 0,
"definition": "The form to be used for printing the content.",
"short": "Printed Form Identifier",
"mapping": [ {
"map": "G42",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "required",
"description": "The forms codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/forms"
}
},
"max": "1",
"id": "ClaimResponse.form"
}, {
"id": "ClaimResponse.note",
"max": "*",
"min": 0,
"path": "ClaimResponse.note",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Processing notes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Note"
} ],
"definition": "Note text."
}, {
"id": "ClaimResponse.note.number",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.number",
"type": [ {
"code": "positiveInt"
} ],
"short": "Note Number for this note",
"definition": "An integer associated with each note which may be referred to from each service line item."
}, {
"id": "ClaimResponse.note.type",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.type",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "display | print | printoper",
"binding": {
"strength": "required",
"description": "The presentation types of notes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/note-type"
}
},
"definition": "The note purpose: Print/Display."
}, {
"id": "ClaimResponse.note.text",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.text",
"type": [ {
"code": "string"
} ],
"short": "Note explanatory text",
"mapping": [ {
"map": "G32",
"identity": "cdanetv4"
} ],
"definition": "The note text."
}, {
"id": "ClaimResponse.note.language",
"max": "1",
"min": 0,
"path": "ClaimResponse.note.language",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Language",
"binding": {
"strength": "extensible",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
} ],
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
},
"definition": "The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. \"en\" for English, or \"en-US\" for American English versus \"en-EN\" for England English."
}, {
"id": "ClaimResponse.communicationRequest",
"max": "*",
"min": 0,
"path": "ClaimResponse.communicationRequest",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/CommunicationRequest"
} ],
"short": "Request for additional information",
"definition": "Request for additional supporting or authorizing information, such as: documents, images or resources."
}, {
"path": "ClaimResponse.insurance",
"requirements": "Health care programs and insurers are significant payors of health service costs.",
"min": 0,
"definition": "Financial instrument by which payment information for health care.",
"short": "Insurance or medical plan",
"mapping": [ {
"map": "Coverage",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-explicit-type-name",
"valueString": "Insurance"
} ],
"max": "*",
"id": "ClaimResponse.insurance"
}, {
"id": "ClaimResponse.insurance.sequence",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.sequence",
"type": [ {
"code": "positiveInt"
} ],
"short": "Service instance identifier",
"definition": "A service line item.",
"requirements": "To maintain order of the coverages."
}, {
"id": "ClaimResponse.insurance.focal",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.focal",
"type": [ {
"code": "boolean"
} ],
"short": "Is the focal Coverage",
"definition": "The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.",
"requirements": "To identify which coverage is being adjudicated."
}, {
"id": "ClaimResponse.insurance.coverage",
"max": "1",
"min": 1,
"path": "ClaimResponse.insurance.coverage",
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/Coverage"
} ],
"short": "Insurance information",
"definition": "Reference to the program or plan identification, underwriter or payor.",
"requirements": "Need to identify the issuer to target for processing and for coordination of benefit processing."
}, {
"id": "ClaimResponse.insurance.businessArrangement",
"max": "1",
"min": 0,
"path": "ClaimResponse.insurance.businessArrangement",
"type": [ {
"code": "string"
} ],
"short": "Business agreement",
"definition": "The contract number of a business agreement which describes the terms and conditions."
}, {
"path": "ClaimResponse.insurance.preAuthRef",
"requirements": "To provide any pre-determination or prior authorization reference.",
"min": 0,
"definition": "A list of references from the Insurer to which these services pertain.",
"short": "Pre-Authorization/Determination Reference",
"mapping": [ {
"map": "F03",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "string"
} ],
"max": "*",
"id": "ClaimResponse.insurance.preAuthRef"
}, {
"path": "ClaimResponse.insurance.claimResponse",
"requirements": "Used by downstream payers to determine what balance remains and the net payable.",
"min": 0,
"definition": "The Coverages adjudication details.",
"short": "Adjudication results",
"mapping": [ {
"map": "EOB",
"identity": "cdanetv4"
} ],
"type": [ {
"code": "Reference",
"targetProfile": "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
} ],
"max": "1",
"id": "ClaimResponse.insurance.claimResponse"
} ]
},
"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"
}