ClaimResponse R4B (FHIR) at fhirtruck

Path

ClaimResponse

Id

ClaimResponse

Cardinality

0 - *

Definition

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

Comment

Constraint

dom-2 [error]

If the resource is contained in another resource, it SHALL NOT contain nested Resources

dom-3 [error]

If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource

dom-4 [error]

If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated

dom-5 [error]

If a resource is contained in another resource, it SHALL NOT have a security label

dom-6 [warning]

A resource should have narrative for robust management

Path

ClaimResponse.identifier

Id

ClaimResponse.identifier

Type

Identifier

Cardinality

0 - *

Definition

A unique identifier assigned to this claim response.

Comment

Requirements

Allows claim responses to be distinguished and referenced.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

Summary: The element appears in the summary view

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

coding

List: This element is a list and more than one value can be provided

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

ClaimResponse.status

Id

ClaimResponse.status

Type

code

Cardinality

1 - 1

Definition

The status of the resource instance.

Comment

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Binding

Strength

required

Description

A code specifying the state of the resource instance.

ValueSet

http://hl7.org/fhir/ValueSet/fm-status|4.3.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.type

Id

ClaimResponse.type

Type

CodeableConcept

Cardinality

1 - 1

Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Comment

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Binding

Strength

extensible

Description

The type or discipline-style of the claim.

ValueSet

http://hl7.org/fhir/ValueSet/claim-type

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.subType

Id

ClaimResponse.subType

Type

CodeableConcept

Cardinality

0 - 1

Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

Comment

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Binding

Strength

example

Description

A more granular claim typecode.

ValueSet

http://hl7.org/fhir/ValueSet/claim-subtype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.use

Id

ClaimResponse.use

Type

code

Cardinality

1 - 1

Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Comment

Requirements

This element is required to understand the nature of the request for adjudication.

Binding

Strength

required

Description

Claim, preauthorization, predetermination.

ValueSet

http://hl7.org/fhir/ValueSet/claim-use|4.3.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.patient

Id

ClaimResponse.patient

Type

Reference

Cardinality

1 - 1

Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

Comment

Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.patient.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.patient.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

ClaimResponse.created

Id

ClaimResponse.created

Type

dateTime

Cardinality

1 - 1

Definition

The date this resource was created.

Comment

Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.insurer

Id

ClaimResponse.insurer

Type

Reference

Cardinality

1 - 1

Definition

The party responsible for authorization, adjudication and reimbursement.

Comment

Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.insurer.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.insurer.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

ClaimResponse.requestor

Id

ClaimResponse.requestor

Type

Reference

Cardinality

0 - 1

Definition

The provider which is responsible for the claim, predetermination or preauthorization.

Comment

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.requestor.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.requestor.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

ClaimResponse.request

Id

ClaimResponse.request

Type

Reference

Cardinality

0 - 1

Definition

Original request resource reference.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.request.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.request.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

ClaimResponse.outcome

Id

ClaimResponse.outcome

Type

code

Cardinality

1 - 1

Definition

The outcome of the claim, predetermination, or preauthorization processing.

Comment

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Requirements

To advise the requestor of an overall processing outcome.

Binding

Strength

required

Description

The result of the claim processing.

ValueSet

http://hl7.org/fhir/ValueSet/remittance-outcome|4.3.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.disposition

Id

ClaimResponse.disposition

Type

string

Cardinality

0 - 1

Definition

A human readable description of the status of the adjudication.

Comment

Requirements

Provided for user display.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.preAuthRef

Id

ClaimResponse.preAuthRef

Type

string

Cardinality

0 - 1

Definition

Reference from the Insurer which is used in later communications which refers to this adjudication.

Comment

This value is only present on preauthorization adjudications.

Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.preAuthPeriod

Id

ClaimResponse.preAuthPeriod

Type

Period

Cardinality

0 - 1

Definition

The time frame during which this authorization is effective.

Comment

Requirements

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

Path

ClaimResponse.payeeType

Id

ClaimResponse.payeeType

Type

CodeableConcept

Cardinality

0 - 1

Definition

Type of Party to be reimbursed: subscriber, provider, other.

Comment

Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Binding

Strength

example

Description

A code for the party to be reimbursed.

ValueSet

http://hl7.org/fhir/ValueSet/payeetype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.item

Id

ClaimResponse.item

Type

BackboneElement

Cardinality

0 - *

Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

Comment

Requirements

The adjudication for items provided on the claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.item.itemSequence

Id

ClaimResponse.item.itemSequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely reference the claim item entries.

Comment

Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.noteNumber

Id

ClaimResponse.item.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.adjudication

Id

ClaimResponse.item.adjudication

Type

BackboneElement

Cardinality

1 - *

Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

Comment

Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.item.adjudication.category

Id

ClaimResponse.item.adjudication.category

Type

CodeableConcept

Cardinality

1 - 1

Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

Comment

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Binding

Strength

example

Description

The adjudication codes.

ValueSet

http://hl7.org/fhir/ValueSet/adjudication

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

ClaimResponse.item.adjudication.reason

Id

ClaimResponse.item.adjudication.reason

Type

CodeableConcept

Cardinality

0 - 1

Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

Comment

For example may indicate that the funds for this benefit type have been exhausted.

Requirements

To support understanding of variance from adjudication expectations.

Binding

Strength

example

Description

The adjudication reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/adjudication-reason

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

ClaimResponse.item.adjudication.amount

Id

ClaimResponse.item.adjudication.amount

Type

Money

Cardinality

0 - 1

Definition

Monetary amount associated with the category.

Comment

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Requirements

Most adjuciation categories convey a monetary amount.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.item.adjudication.value

Id

ClaimResponse.item.adjudication.value

Type

decimal

Cardinality

0 - 1

Definition

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

Comment

For example: eligible percentage or co-payment percentage.

Requirements

Some adjudication categories convey a percentage or a fixed value.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail

Id

ClaimResponse.item.detail

Type

BackboneElement

Cardinality

0 - *

Definition

A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

Comment

Requirements

The adjudication for details provided on the claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.item.detail.detailSequence

Id

ClaimResponse.item.detail.detailSequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely reference the claim detail entry.

Comment

Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail.noteNumber

Id

ClaimResponse.item.detail.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail.adjudication

Id

ClaimResponse.item.detail.adjudication

Type

ClaimResponse.item.detail.adjudication

Cardinality

1 - *

Definition

The adjudication results.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail.subDetail

Id

ClaimResponse.item.detail.subDetail

Type

BackboneElement

Cardinality

0 - *

Definition

A sub-detail adjudication of a simple product or service.

Comment

Requirements

The adjudication for sub-details provided on the claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.item.detail.subDetail.subDetailSequence

Id

ClaimResponse.item.detail.subDetail.subDetailSequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely reference the claim sub-detail entry.

Comment

Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail.subDetail.noteNumber

Id

ClaimResponse.item.detail.subDetail.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.item.detail.subDetail.adjudication

Id

ClaimResponse.item.detail.subDetail.adjudication

Type

ClaimResponse.item.detail.subDetail.adjudication

Cardinality

0 - *

Definition

The adjudication results.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem

Id

ClaimResponse.addItem

Type

BackboneElement

Cardinality

0 - *

Definition

The first-tier service adjudications for payor added product or service lines.

Comment

Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.addItem.itemSequence

Id

ClaimResponse.addItem.itemSequence

Type

positiveInt

Cardinality

0 - *

Definition

Claim items which this service line is intended to replace.

Comment

Requirements

Provides references to the claim items.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detailSequence

Id

ClaimResponse.addItem.detailSequence

Type

positiveInt

Cardinality

0 - *

Definition

The sequence number of the details within the claim item which this line is intended to replace.

Comment

Requirements

Provides references to the claim details within the claim item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.subdetailSequence

Id

ClaimResponse.addItem.subdetailSequence

Type

positiveInt

Cardinality

0 - *

Definition

The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

Comment

Requirements

Provides references to the claim sub-details within the claim detail.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.provider

Id

ClaimResponse.addItem.provider

Type

Reference

Cardinality

0 - *

Definition

The providers who are authorized for the services rendered to the patient.

Comment

Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.addItem.provider.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

ClaimResponse.addItem.productOrService

Id

ClaimResponse.addItem.productOrService

Type

CodeableConcept

Cardinality

1 - 1

Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Comment

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Requirements

Necessary to state what was provided or done.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.modifier

Id

ClaimResponse.addItem.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

Item typification or modifiers codes to convey additional context for the product or service.

Comment

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

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.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.programCode

Id

ClaimResponse.addItem.programCode

Type

CodeableConcept

Cardinality

0 - *

Definition

Identifies the program under which this may be recovered.

Comment

For example: Neonatal program, child dental program or drug users recovery program.

Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Binding

Strength

example

Description

Program specific reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/ex-program-code

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.serviced[x]

Id

ClaimResponse.addItem.serviced[x]

Type

date

Cardinality

0 - 1

Definition

The date or dates when the service or product was supplied, performed or completed.

Comment

Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.location[x]

Id

ClaimResponse.addItem.location[x]

Type

CodeableConcept

Cardinality

0 - 1

Definition

Where the product or service was provided.

Comment

Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Binding

Strength

example

Description

Place of service: pharmacy, school, prison, etc.

ValueSet

http://hl7.org/fhir/ValueSet/service-place

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.quantity

Id

ClaimResponse.addItem.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

Required when the product or service code does not convey the quantity provided.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

comparator

code

< | <= | >= | > - how to understand the value

unit

string

Unit representation

system

uri

System that defines coded unit form

code

Coded form of the unit

Path

ClaimResponse.addItem.unitPrice

Id

ClaimResponse.addItem.unitPrice

Type

Money

Cardinality

0 - 1

Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Comment

Requirements

The amount charged to the patient by the provider for a single unit.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.addItem.factor

Id

ClaimResponse.addItem.factor

Type

decimal

Cardinality

0 - 1

Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Comment

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.net

Id

ClaimResponse.addItem.net

Type

Money

Cardinality

0 - 1

Definition

The quantity times the unit price for an additional service or product or charge.

Comment

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.addItem.bodySite

Id

ClaimResponse.addItem.bodySite

Type

CodeableConcept

Cardinality

0 - 1

Definition

Physical service site on the patient (limb, tooth, etc.).

Comment

For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Requirements

Allows insurer to validate specific procedures.

Binding

Strength

example

Description

The code for the teeth, quadrant, sextant and arch.

ValueSet

http://hl7.org/fhir/ValueSet/tooth

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.subSite

Id

ClaimResponse.addItem.subSite

Type

CodeableConcept

Cardinality

0 - *

Definition

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

Comment

Requirements

Allows insurer to validate specific procedures.

Binding

Strength

example

Description

The code for the tooth surface and surface combinations.

ValueSet

http://hl7.org/fhir/ValueSet/surface

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.addItem.noteNumber

Id

ClaimResponse.addItem.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.adjudication

Id

ClaimResponse.addItem.adjudication

Type

ClaimResponse.addItem.adjudication

Cardinality

1 - *

Definition

The adjudication results.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail

Id

ClaimResponse.addItem.detail

Type

BackboneElement

Cardinality

0 - *

Definition

The second-tier service adjudications for payor added services.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.addItem.detail.productOrService

Id

ClaimResponse.addItem.detail.productOrService

Type

CodeableConcept

Cardinality

1 - 1

Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Comment

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Requirements

Necessary to state what was provided or done.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

ClaimResponse.addItem.detail.modifier

Id

ClaimResponse.addItem.detail.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

Item typification or modifiers codes to convey additional context for the product or service.

Comment

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

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.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

Path

ClaimResponse.addItem.detail.quantity

Id

ClaimResponse.addItem.detail.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

Required when the product or service code does not convey the quantity provided.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

comparator

code

< | <= | >= | > - how to understand the value

unit

string

Unit representation

system

uri

System that defines coded unit form

code

Coded form of the unit

Path

ClaimResponse.addItem.detail.unitPrice

Id

ClaimResponse.addItem.detail.unitPrice

Type

Money

Cardinality

0 - 1

Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Comment

Requirements

The amount charged to the patient by the provider for a single unit.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.addItem.detail.factor

Id

ClaimResponse.addItem.detail.factor

Type

decimal

Cardinality

0 - 1

Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Comment

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.net

Id

ClaimResponse.addItem.detail.net

Type

Money

Cardinality

0 - 1

Definition

The quantity times the unit price for an additional service or product or charge.

Comment

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.addItem.detail.noteNumber

Id

ClaimResponse.addItem.detail.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.adjudication

Id

ClaimResponse.addItem.detail.adjudication

Type

ClaimResponse.addItem.detail.adjudication

Cardinality

1 - *

Definition

The adjudication results.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail

Id

ClaimResponse.addItem.detail.subDetail

Type

BackboneElement

Cardinality

0 - *

Definition

The third-tier service adjudications for payor added services.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.addItem.detail.subDetail.productOrService

Id

ClaimResponse.addItem.detail.subDetail.productOrService

Type

CodeableConcept

Cardinality

1 - 1

Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

Comment

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Requirements

Necessary to state what was provided or done.

Binding

Strength

example

Description

Allowable service and product codes.

ValueSet

http://hl7.org/fhir/ValueSet/service-uscls

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.modifier

Id

ClaimResponse.addItem.detail.subDetail.modifier

Type

CodeableConcept

Cardinality

0 - *

Definition

Item typification or modifiers codes to convey additional context for the product or service.

Comment

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

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.

ValueSet

http://hl7.org/fhir/ValueSet/claim-modifiers

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.quantity

Id

ClaimResponse.addItem.detail.subDetail.quantity

Type

Quantity

Cardinality

0 - 1

Definition

The number of repetitions of a service or product.

Comment

Requirements

Required when the product or service code does not convey the quantity provided.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.unitPrice

Id

ClaimResponse.addItem.detail.subDetail.unitPrice

Type

Money

Cardinality

0 - 1

Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

Comment

Requirements

The amount charged to the patient by the provider for a single unit.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.factor

Id

ClaimResponse.addItem.detail.subDetail.factor

Type

decimal

Cardinality

0 - 1

Definition

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

Comment

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.net

Id

ClaimResponse.addItem.detail.subDetail.net

Type

Money

Cardinality

0 - 1

Definition

The quantity times the unit price for an additional service or product or charge.

Comment

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.noteNumber

Id

ClaimResponse.addItem.detail.subDetail.noteNumber

Type

positiveInt

Cardinality

0 - *

Definition

The numbers associated with notes below which apply to the adjudication of this item.

Comment

Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.addItem.detail.subDetail.adjudication

Id

ClaimResponse.addItem.detail.subDetail.adjudication

Type

ClaimResponse.addItem.detail.subDetail.adjudication

Cardinality

1 - *

Definition

The adjudication results.

Comment

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.adjudication

Id

ClaimResponse.adjudication

Type

ClaimResponse.adjudication

Cardinality

0 - *

Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

Comment

Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.total

Id

ClaimResponse.total

Type

BackboneElement

Cardinality

0 - *

Definition

Categorized monetary totals for the adjudication.

Comment

Totals for amounts submitted, co-pays, benefits payable etc.

Requirements

To provide the requestor with financial totals by category for the adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.total.category

Id

ClaimResponse.total.category

Type

CodeableConcept

Cardinality

1 - 1

Definition

A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

Comment

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Requirements

Needed to convey the type of total provided.

Binding

Strength

example

Description

The adjudication codes.

ValueSet

http://hl7.org/fhir/ValueSet/adjudication

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.total.amount

Id

ClaimResponse.total.amount

Type

Money

Cardinality

1 - 1

Definition

Monetary total amount associated with the category.

Comment

Requirements

Needed to convey the total monetary amount.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.payment

Id

ClaimResponse.payment

Type

BackboneElement

Cardinality

0 - 1

Definition

Payment details for the adjudication of the claim.

Comment

Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.payment.type

Id

ClaimResponse.payment.type

Type

CodeableConcept

Cardinality

1 - 1

Definition

Whether this represents partial or complete payment of the benefits payable.

Comment

Requirements

To advise the requestor when the insurer believes all payments to have been completed.

Binding

Strength

example

Description

The type (partial, complete) of the payment.

ValueSet

http://hl7.org/fhir/ValueSet/ex-paymenttype

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.payment.adjustment

Id

ClaimResponse.payment.adjustment

Type

Money

Cardinality

0 - 1

Definition

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

Comment

Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

Requirements

To advise the requestor of adjustments applied to the payment.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.payment.adjustmentReason

Id

ClaimResponse.payment.adjustmentReason

Type

CodeableConcept

Cardinality

0 - 1

Definition

Reason for the payment adjustment.

Comment

Requirements

Needed to clarify the monetary adjustment.

Binding

Strength

example

Description

Payment Adjustment reason codes.

ValueSet

http://hl7.org/fhir/ValueSet/payment-adjustment-reason

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.payment.date

Id

ClaimResponse.payment.date

Type

date

Cardinality

0 - 1

Definition

Estimated date the payment will be issued or the actual issue date of payment.

Comment

Requirements

To advise the payee when payment can be expected.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.payment.amount

Id

ClaimResponse.payment.amount

Type

Money

Cardinality

1 - 1

Definition

Benefits payable less any payment adjustment.

Comment

Requirements

Needed to provide the actual payment amount.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

value

decimal

Numerical value (with implicit precision)

currency

code

ISO 4217 Currency Code

Path

ClaimResponse.payment.identifier

Id

ClaimResponse.payment.identifier

Type

Identifier

Cardinality

0 - 1

Definition

Issuer's unique identifier for the payment instrument.

Comment

For example: EFT number or check number.

Requirements

Enable the receiver to reconcile when payment received.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.payment.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

Path

ClaimResponse.fundsReserve

Id

ClaimResponse.fundsReserve

Type

CodeableConcept

Cardinality

0 - 1

Definition

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

Comment

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Binding

Strength

example

Description

For whom funds are to be reserved: (Patient, Provider, None).

ValueSet

http://hl7.org/fhir/ValueSet/fundsreserve

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.formCode

Id

ClaimResponse.formCode

Type

CodeableConcept

Cardinality

0 - 1

Definition

A code for the form to be used for printing the content.

Comment

May be needed to identify specific jurisdictional forms.

Requirements

Needed to specify the specific form used for producing output for this response.

Binding

Strength

example

Description

The forms codes.

ValueSet

http://hl7.org/fhir/ValueSet/forms

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user

Path

ClaimResponse.form

Id

ClaimResponse.form

Type

Attachment

Cardinality

0 - 1

Definition

The actual form, by reference or inclusion, for printing the content or an EOB.

Comment

Needed to permit insurers to include the actual form.

Requirements

Needed to include the specific form used for producing output for this response.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

contentType

code

Mime type of the content, with charset etc.

data

base64Binary

Data inline, base64ed

url

Uri where the data can be found

size

unsignedInt

Number of bytes of content (if url provided)

hash

base64Binary

Hash of the data (sha-1, base64ed)

title

string

Label to display in place of the data

creation

dateTime

Date attachment was first created

Path

ClaimResponse.processNote

Id

ClaimResponse.processNote

Type

BackboneElement

Cardinality

0 - *

Definition

A note that describes or explains adjudication results in a human readable form.

Comment

Requirements

Provides the insurer specific textual explanations associated with the processing.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.processNote.number

Id

ClaimResponse.processNote.number

Type

positiveInt

Cardinality

0 - 1

Definition

A number to uniquely identify a note entry.

Comment

Requirements

Necessary to provide a mechanism to link from adjudications.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.processNote.type

Id

ClaimResponse.processNote.type

Type

code

Cardinality

0 - 1

Definition

The business purpose of the note text.

Comment

Requirements

To convey the expectation for when the text is used.

Binding

Strength

required

Description

The presentation types of notes.

ValueSet

http://hl7.org/fhir/ValueSet/note-type|4.3.0

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.communicationRequest

Id

ClaimResponse.communicationRequest

Type

Reference

Cardinality

0 - *

Definition

Request for additional supporting or authorizing information.

Comment

For example: professional reports, documents, images, clinical resources, or accident reports.

Requirements

Need to communicate insurer request for additional information required to support the adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.communicationRequest.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

start

dateTime

Starting time with inclusive boundary

end

dateTime

End time with inclusive boundary, if not ongoing

assigner

Reference

Organization that issued id (may be just text)

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.communicationRequest.Reference.identifier.Identifier.assigner.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

display

string

Text alternative for the resource

display

string

Text alternative for the resource

Path

ClaimResponse.insurance

Id

ClaimResponse.insurance

Type

BackboneElement

Cardinality

0 - *

Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

Comment

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Requirements

At least one insurer is required for a claim to be a claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.insurance.sequence

Id

ClaimResponse.insurance.sequence

Type

positiveInt

Cardinality

1 - 1

Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

Comment

Requirements

To maintain order of the coverages.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.insurance.focal

Id

ClaimResponse.insurance.focal

Type

boolean

Cardinality

1 - 1

Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

Comment

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.insurance.coverage

Id

ClaimResponse.insurance.coverage

Type

Reference

Cardinality

1 - 1

Definition

Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

Comment

Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.insurance.coverage.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

ClaimResponse.insurance.businessArrangement

Id

ClaimResponse.insurance.businessArrangement

Type

string

Cardinality

0 - 1

Definition

A business agreement number established between the provider and the insurer for special business processing purposes.

Comment

Requirements

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.insurance.claimResponse

Id

ClaimResponse.insurance.claimResponse

Type

Reference

Cardinality

0 - 1

Definition

The result of the adjudication of the line items for the Coverage specified in this insurance.

Comment

Must not be specified when 'focal=true' for this insurance.

Requirements

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

reference

string

Literal reference, Relative, internal or absolute URL

type

uri

Type the reference refers to (e.g. "Patient")

identifier

Identifier

Logical reference, when literal reference is not known

Path

ClaimResponse.insurance.claimResponse.Reference.identifier

Id

Reference.identifier

Type

Identifier

Cardinality

0 - 1

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comment

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

use

code

usual | official | temp | secondary | old (If known)

type

CodeableConcept

Description of identifier

system

uri

The namespace for the identifier value

value

string

The value that is unique

period

Period

Time period when id is/was valid for use

assigner

Reference

Organization that issued id (may be just text)

display

string

Text alternative for the resource

Path

ClaimResponse.error

Id

ClaimResponse.error

Type

BackboneElement

Cardinality

0 - *

Definition

Errors encountered during the processing of the adjudication.

Comment

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Requirements

Need to communicate processing issues to the requestor.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children unless an empty Parameters resource

Path

ClaimResponse.error.itemSequence

Id

ClaimResponse.error.itemSequence

Type

positiveInt

Cardinality

0 - 1

Definition

The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Comment

Requirements

Provides references to the claim items.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.error.detailSequence

Id

ClaimResponse.error.detailSequence

Type

positiveInt

Cardinality

0 - 1

Definition

The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Comment

Requirements

Provides references to the claim details within the claim item.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.error.subDetailSequence

Id

ClaimResponse.error.subDetailSequence

Type

positiveInt

Cardinality

0 - 1

Definition

The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Comment

Requirements

Provides references to the claim sub-details within the claim detail.

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

Path

ClaimResponse.error.code

Id

ClaimResponse.error.code

Type

CodeableConcept

Cardinality

1 - 1

Definition

An error code, from a specified code system, which details why the claim could not be adjudicated.

Comment

Requirements

Required to convey processing errors.

Binding

Strength

example

Description

The adjudication error codes.

ValueSet

http://hl7.org/fhir/ValueSet/adjudication-error

Constraint

ele-1 [error]

All FHIR elements must have a @value or children

coding

Coding

Code defined by a terminology system

system

uri

Identity of the terminology system

version

string

Version of the system - if relevant

code

Symbol in syntax defined by the system

display

string

Representation defined by the system

userSelected

boolean

If this coding was chosen directly by the user