MII IG Molekulares Tumorboard DE v2025

Antwort Kostenuebernahme: ClaimResponse

Inhalt

Dieses Profil beschreibt die Antwort auf den Antrag zur Kostenuebernahme (MII_PR_Antrag_Kostenuebernahme). Sie basieren auf dem Financial-Ressource ClaimResponse. CAVE: Der Lifecycle-Status einer Financial-Ressource entspricht nicht den bekannten Workflows. Die Financial-Ressourcen unterhalten ein eigenes ValueSet mit eigenen Semantischen Bedeutungen (siehe https://hl7.org/fhir/R4/valueset-fm-status.html). Eine ClaimResponse sollte daher im Normalfall immer active sein, solange sie nicht zurückgezogen wurde.

Beziehungen zu anderen Ressourcen

Der vorausgegangene Antrag zur Kostenuebernahme wird über das Element ClaimResponse.request referenziert. Dort sind auch die Referenzen zur beantragten Diagnostik / Therapie als ServiceRequest / MedicationRequest / RequestGroup.
D

Alternative Profilierungen / Ballot-Unterstützung

Sowohl Entscheidung als auch Ablehungsgrund ist hier als extension hinterlegt. Hier wäre alternativ der reguläre FHIR-R5-Backport des in R5 dazugekommen ClaimResponse.decision-Elements als Ersatz .
Wie auch schon beim Claim wäre auf Basis der retrospektiven Erschließung die ExplanationOfBenefit-Ressource als Kombination von Claims und ClaimResponses denkbar

Name	Status	Version	Canonical	Basis
MII_PR_MTB_Antwort_Kostenuebernahme	draft	2024.0.0-ballot	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme	http://hl7.org/fhir/StructureDefinition/ClaimResponse

Inhalt

MII_PR_MTB_Antwort_Kostenuebernahme (ClaimResponse)	I		ClaimResponse	There are no (further) constraints on this element Element id ClaimResponse Short description Response to a claim predetermination or preauthorization Alternate names Remittance Advice Definition This resource provides the adjudication details from the processing of a Claim resource. Data type ClaimResponse Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: 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 `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event
id	Σ	0..1	string	There are no (further) constraints on this element Element id ClaimResponse.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	S Σ	0..1	Meta	There are no (further) constraints on this element Element id ClaimResponse.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.meta.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.meta.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id ClaimResponse.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id ClaimResponse.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
source	Σ	0..1	uri	There are no (further) constraints on this element Element id ClaimResponse.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id ClaimResponse.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id ClaimResponse.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id ClaimResponse.meta.tag Short description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id ClaimResponse.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id ClaimResponse.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id ClaimResponse.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id ClaimResponse.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	S I	0..*	Extension	Element id ClaimResponse.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
Entscheidung	S I	0..1	Extension(CodeableConcept)	Element id ClaimResponse.extension:Entscheidung Short description Entscheidung Alternate names extensions, user content Definition Stadium der Antwort auf den Antrag zur Kostenuebernahme Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension(CodeableConcept) Extension URL https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A rim: n/a
Ablehnungsgrund	I	0..1	Extension(CodeableConcept)	Element id ClaimResponse.extension:Ablehnungsgrund Short description Ablehnungsgrund Alternate names extensions, user content Definition Stadium der Antwort auf den Antrag zur Kostenuebernahme Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension(CodeableConcept) Extension URL https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A rim: n/a
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier		0..*	Identifier	There are no (further) constraints on this element Element id ClaimResponse.identifier Short description Business Identifier for a claim response Definition A unique identifier assigned to this claim response. Requirements Allows claim responses to be distinguished and referenced. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.identifier w5: FiveWs.identifier
status	S Σ ?!	1..1	codeBindingPattern	Element id ClaimResponse.status Short description Status der FHIR-Ressource Definition Status der FHIR-Ressource, statisch auf #active gesetzt, da retrospektive Datenerschließung 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'. Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding A code specifying the state of the resource instance. FinancialResourceStatusCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern active Mappings workflow: Event.status w5: FiveWs.status
type	S Σ	1..1	CodeableConceptBinding	Element id ClaimResponse.type Short description Kategorie des Antragstellers Definition Kategorie des Antragstellers - z.B. stationär, ambulant, Apotheke Requirements Some jurisdictions need a finer grained claim type for routing and adjudication. Comments This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. Data type CodeableConcept Binding The type or discipline-style of the claim. MII_VS_MTB_Antrag_Kostenuebernahme_Type (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class
subType		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.subType Short description More granular claim type Definition A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Requirements Some jurisdictions need a finer grained claim type for routing and adjudication. Comments This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. Data type CodeableConcept Binding A more granular claim typecode. ExampleClaimSubTypeCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class
use	S Σ	1..1	codeBinding	Element id ClaimResponse.use Short description Art des Kostenerstattungsantrags (claim, predetermination, preauthorization) Definition folgt den Definitionen wie im amerikanischen Gesundsheitswesen gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme; preauthorization: Anfrage nach möglicher Erstattung für zukünftige Therapie Requirements This element is required to understand the nature of the request for adjudication. Data type code Binding Claim, preauthorization, predetermination. Use (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class
patient	S Σ	1..1	Reference(Patient)	There are no (further) constraints on this element Element id ClaimResponse.patient Short description The recipient of the products and services 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. 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. Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] w5: FiveWs.subject
created	S Σ	1..1	dateTime	Element id ClaimResponse.created Short description Datum der Zusage / des Widerspruchs Definition The date this resource was created. Requirements Need to record a timestamp for use by both the recipient and the issuer. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.recorded
insurer	S Σ	1..1	Reference(Organization)	There are no (further) constraints on this element Element id ClaimResponse.insurer Short description Party responsible for reimbursement Definition The party responsible for authorization, adjudication and reimbursement. 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. Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer
requestor		0..1	Reference(Practitioner \| PractitionerRole \| Organization)	There are no (further) constraints on this element Element id ClaimResponse.requestor Short description Party responsible for the claim Definition The provider which is responsible for the claim, predetermination or preauthorization. Comments 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. Data type Reference(Practitioner \| PractitionerRole \| Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.source
request	S Σ	0..1	Reference(MII_PR_MTB_Antrag_Kostenuebernahme)	Element id ClaimResponse.request Short description Antrag Definition Dazugehöriger Antrag zur Kostenübernahme Data type Reference(MII_PR_MTB_Antrag_Kostenuebernahme) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.basedOn w5: FiveWs.why[x]
outcome	S Σ	1..1	codeBindingPattern	Element id ClaimResponse.outcome Short description Ergebnis der Kostenübernahme Definition Ergebnis der Kostenübernahme. Für den Fall der Sekundärdatenenutzung ist davon auszugehen, dass die Kostenerstattung bereits erfolgt ist. Daher ist der Status auf #complete gesetzt. Requirements To advise the requestor of an overall processing outcome. Comments 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). Data type code Binding The result of the claim processing. ClaimProcessingCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern complete
disposition		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.disposition Short description Disposition Message Definition A human readable description of the status of the adjudication. Requirements Provided for user display. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.note
preAuthRef		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.preAuthRef Short description Preauthorization reference Definition Reference from the Insurer which is used in later communications which refers to this adjudication. Requirements On subsequent claims, the insurer may require the provider to quote this value. Comments This value is only present on preauthorization adjudications. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
preAuthPeriod		0..1	Period	There are no (further) constraints on this element Element id ClaimResponse.preAuthPeriod Short description Preauthorization reference effective period Definition The time frame during which this authorization is effective. Requirements To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
payeeType		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.payeeType Short description Party to be paid any benefits payable Definition Type of Party to be reimbursed: subscriber, provider, other. Requirements Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. Data type CodeableConcept Binding A code for the party to be reimbursed. Claim Payee Type Codes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
item		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.item Short description Adjudication for claim line items 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. Requirements The adjudication for items provided on the claim. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		1..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.itemSequence Short description Claim item instance identifier Definition A number to uniquely reference the claim item entries. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication Short description Adjudication details 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. 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. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
category		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.category Short description Type of adjudication information 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. Requirements Needed to enable understanding of the context of the other information in the adjudication. Comments For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Data type CodeableConcept Binding The adjudication codes. AdjudicationValueCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
reason		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.reason Short description Explanation of adjudication outcome Definition A code supporting the understanding of the adjudication result and explaining variance from expected amount. Requirements To support understanding of variance from adjudication expectations. Comments For example may indicate that the funds for this benefit type have been exhausted. Data type CodeableConcept Binding The adjudication reason codes. AdjudicationReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
amount		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.amount Short description Monetary amount Definition Monetary amount associated with the category. Requirements Most adjuciation categories convey a monetary amount. Comments For example: amount submitted, eligible amount, co-payment, and benefit payable. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
value		0..1	decimal	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.value Short description Non-monetary value Definition A non-monetary value associated with the category. Mutually exclusive to the amount element above. Requirements Some adjudication categories convey a percentage or a fixed value. Comments For example: eligible percentage or co-payment percentage. Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detail		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.item.detail Short description Adjudication for claim details Definition A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items. Requirements The adjudication for details provided on the claim. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.detail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
detailSequence		1..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.detail.detailSequence Short description Claim detail instance identifier Definition A number to uniquely reference the claim detail entry. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.detail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.item.detail.adjudication Short description Detail level adjudication details Definition The adjudication results. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subDetail		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail Short description Adjudication for claim sub-details Definition A sub-detail adjudication of a simple product or service. Requirements The adjudication for sub-details provided on the claim. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
subDetailSequence		1..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.subDetailSequence Short description Claim sub-detail instance identifier Definition A number to uniquely reference the claim sub-detail entry. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		0..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.adjudication Short description Subdetail level adjudication details Definition The adjudication results. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
addItem		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.addItem Short description Insurer added line items Definition The first-tier service adjudications for payor added product or service lines. 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. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.itemSequence Short description Item sequence number Definition Claim items which this service line is intended to replace. Requirements Provides references to the claim items. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detailSequence		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.detailSequence Short description Detail sequence number Definition The sequence number of the details within the claim item which this line is intended to replace. Requirements Provides references to the claim details within the claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subdetailSequence		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.subdetailSequence Short description Subdetail sequence number Definition The sequence number of the sub-details within the details within the claim item which this line is intended to replace. Requirements Provides references to the claim sub-details within the claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
provider		0..*	Reference(Practitioner \| PractitionerRole \| Organization)	There are no (further) constraints on this element Element id ClaimResponse.addItem.provider Short description Authorized providers Definition The providers who are authorized for the services rendered to the patient. Requirements Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. Data type Reference(Practitioner \| PractitionerRole \| Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.source
productOrService		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.productOrService Short description Billing, service, product, or drug code 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. Requirements Necessary to state what was provided or done. Comments 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'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
modifier		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments 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. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.C, 24.D mods
programCode		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.programCode Short description Program the product or service is provided under Definition Identifies the program under which this may be recovered. Requirements Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. Comments For example: Neonatal program, child dental program or drug users recovery program. Data type CodeableConcept Binding Program specific reason codes. ExampleProgramReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.H
serviced[x]		0..1		There are no (further) constraints on this element Element id ClaimResponse.addItem.serviced[x] Short description Date or dates of service or product delivery Definition The date or dates when the service or product was supplied, performed or completed. Requirements Needed to determine whether the service or product was provided during the term of the insurance coverage. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.done[x] rim: 24.A
servicedDate			date	There are no (further) constraints on this element Data type date
servicedPeriod			Period	There are no (further) constraints on this element Data type Period
location[x]		0..1		There are no (further) constraints on this element Element id ClaimResponse.addItem.location[x] Short description Place of service or where product was supplied Definition Where the product or service was provided. Requirements The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Binding Place of service: pharmacy, school, prison, etc. ExampleServicePlaceCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.where[x] rim: 24.B
locationCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
locationAddress			Address	There are no (further) constraints on this element Data type Address
locationReference			Reference(Location)	There are no (further) constraints on this element Data type Reference(Location)
quantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id ClaimResponse.addItem.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.G
unitPrice		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.unitPrice Short description Fee, charge or cost per item 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. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
factor		0..1	decimal	There are no (further) constraints on this element Element id ClaimResponse.addItem.factor Short description Price scaling factor 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. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.F
bodySite		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.bodySite Short description Anatomical location Definition Physical service site on the patient (limb, tooth, etc.). Requirements Allows insurer to validate specific procedures. Comments For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. Data type CodeableConcept Binding The code for the teeth, quadrant, sextant and arch. OralSiteCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subSite		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.subSite Short description Anatomical sub-location Definition A region or surface of the bodySite, e.g. limb region or tooth surface(s). Requirements Allows insurer to validate specific procedures. Data type CodeableConcept Binding The code for the tooth surface and surface combinations. SurfaceCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.adjudication Short description Added items adjudication Definition The adjudication results. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detail		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail Short description Insurer added line details Definition The second-tier service adjudications for payor added services. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
productOrService		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.productOrService Short description Billing, service, product, or drug code 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. Requirements Necessary to state what was provided or done. Comments 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'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
modifier		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments 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. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.C, 24.D mods
quantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.G
unitPrice		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.unitPrice Short description Fee, charge or cost per item 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. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
factor		0..1	decimal	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.factor Short description Price scaling factor 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. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.F
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.adjudication Short description Added items detail adjudication Definition The adjudication results. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subDetail		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail Short description Insurer added line items Definition The third-tier service adjudications for payor added services. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
productOrService		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.productOrService Short description Billing, service, product, or drug code 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. Requirements Necessary to state what was provided or done. Comments 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'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
modifier		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments 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. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.C, 24.D mods
quantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.G
unitPrice		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.unitPrice Short description Fee, charge or cost per item 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. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
factor		0..1	decimal	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.factor Short description Price scaling factor 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. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: 24.F
noteNumber		0..*	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.adjudication Short description Added items detail adjudication Definition The adjudication results. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		0..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.adjudication Short description Header-level adjudication Definition The adjudication results which are presented at the header level rather than at the line-item or add-item levels. Requirements Some insurers will receive line-items but provide the adjudication only at a summary or header-level. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
total	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.total Short description Adjudication totals Definition Categorized monetary totals for the adjudication. Requirements To provide the requestor with financial totals by category for the adjudication. Comments Totals for amounts submitted, co-pays, benefits payable etc. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.total.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.total.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.total.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
category	Σ	1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.total.category Short description Type of adjudication information 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. Requirements Needed to convey the type of total provided. Comments For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Data type CodeableConcept Binding The adjudication codes. AdjudicationValueCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
amount	Σ	1..1	Money	There are no (further) constraints on this element Element id ClaimResponse.total.amount Short description Financial total for the category Definition Monetary total amount associated with the category. Requirements Needed to convey the total monetary amount. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
payment		0..1	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.payment Short description Payment Details Definition Payment details for the adjudication of the claim. Requirements Needed to convey references to the financial instrument that has been used if payment has been made. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.payment.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.payment.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.payment.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
type		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.payment.type Short description Partial or complete payment Definition Whether this represents partial or complete payment of the benefits payable. Requirements To advise the requestor when the insurer believes all payments to have been completed. Data type CodeableConcept Binding The type (partial, complete) of the payment. ExamplePaymentTypeCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjustment		0..1	Money	There are no (further) constraints on this element Element id ClaimResponse.payment.adjustment Short description Payment adjustment for non-claim issues Definition Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. Requirements To advise the requestor of adjustments applied to the payment. Comments 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. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjustmentReason		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.payment.adjustmentReason Short description Explanation for the adjustment Definition Reason for the payment adjustment. Requirements Needed to clarify the monetary adjustment. Data type CodeableConcept Binding Payment Adjustment reason codes. PaymentAdjustmentReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
date		0..1	date	There are no (further) constraints on this element Element id ClaimResponse.payment.date Short description Expected date of payment Definition Estimated date the payment will be issued or the actual issue date of payment. Requirements To advise the payee when payment can be expected. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
amount		1..1	Money	There are no (further) constraints on this element Element id ClaimResponse.payment.amount Short description Payable amount after adjustment Definition Benefits payable less any payment adjustment. Requirements Needed to provide the actual payment amount. Data type Money Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
identifier		0..1	Identifier	There are no (further) constraints on this element Element id ClaimResponse.payment.identifier Short description Business identifier for the payment Definition Issuer's unique identifier for the payment instrument. Requirements Enable the receiver to reconcile when payment received. Comments For example: EFT number or check number. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
fundsReserve		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.fundsReserve Short description Funds reserved status Definition A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Requirements Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Comments Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. Data type CodeableConcept Binding For whom funds are to be reserved: (Patient, Provider, None). Funds Reservation Codes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
formCode		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.formCode Short description Printed form identifier Definition A code for the form to be used for printing the content. Requirements Needed to specify the specific form used for producing output for this response. Comments May be needed to identify specific jurisdictional forms. Data type CodeableConcept Binding The forms codes. Form Codes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
form		0..1	Attachment	There are no (further) constraints on this element Element id ClaimResponse.form Short description Printed reference or actual form Definition The actual form, by reference or inclusion, for printing the content or an EOB. Requirements Needed to include the specific form used for producing output for this response. Comments Needed to permit insurers to include the actual form. Data type Attachment Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
processNote		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.processNote Short description Note concerning adjudication Definition A note that describes or explains adjudication results in a human readable form. Requirements Provides the insurer specific textual explanations associated with the processing. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.processNote.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.processNote.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.processNote.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
number		0..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.processNote.number Short description Note instance identifier Definition A number to uniquely identify a note entry. Requirements Necessary to provide a mechanism to link from adjudications. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
type		0..1	codeBinding	There are no (further) constraints on this element Element id ClaimResponse.processNote.type Short description display \| print \| printoper Definition The business purpose of the note text. Requirements To convey the expectation for when the text is used. Data type code Binding The presentation types of notes. NoteType (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		1..1	string	There are no (further) constraints on this element Element id ClaimResponse.processNote.text Short description Note explanatory text Definition The explanation or description associated with the processing. Requirements Required to provide human readable explanation. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id ClaimResponse.processNote.language Short description Language of the text Definition A code to define the language used in the text of the note. Requirements Note text may vary from the resource defined language. Comments Only required if the language is different from the resource language. Data type CodeableConcept Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
communicationRequest		0..*	Reference(CommunicationRequest)	There are no (further) constraints on this element Element id ClaimResponse.communicationRequest Short description Request for additional information Definition Request for additional supporting or authorizing information. Requirements Need to communicate insurer request for additional information required to support the adjudication. Comments For example: professional reports, documents, images, clinical resources, or accident reports. Data type Reference(CommunicationRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
insurance		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.insurance Short description Patient insurance information Definition Financial instruments for reimbursement for the health care products and services specified on the claim. Requirements At least one insurer is required for a claim to be a claim. Comments 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. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Coverage
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.insurance.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.insurance.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.insurance.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
sequence		1..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.insurance.sequence Short description Insurance instance identifier Definition A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. Requirements To maintain order of the coverages. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
focal		1..1	boolean	There are no (further) constraints on this element Element id ClaimResponse.insurance.focal Short description Coverage to be used for adjudication Definition A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. Requirements To identify which coverage in the list is being used to adjudicate this claim. Comments 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
coverage		1..1	Reference(Coverage)	There are no (further) constraints on this element Element id ClaimResponse.insurance.coverage Short description Insurance information 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. Requirements Required to allow the adjudicator to locate the correct policy and history within their information system. Data type Reference(Coverage) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
businessArrangement		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.insurance.businessArrangement Short description Additional provider contract number Definition A business agreement number established between the provider and the insurer for special business processing purposes. Requirements Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
claimResponse		0..1	Reference(ClaimResponse)	There are no (further) constraints on this element Element id ClaimResponse.insurance.claimResponse Short description Adjudication results Definition The result of the adjudication of the line items for the Coverage specified in 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. Comments Must not be specified when 'focal=true' for this insurance. Data type Reference(ClaimResponse) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
error		0..*	BackboneElement	There are no (further) constraints on this element Element id ClaimResponse.error Short description Processing errors Definition Errors encountered during the processing of the adjudication. Requirements Need to communicate processing issues to the requestor. Comments If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.error.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.error.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.error.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		0..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.error.itemSequence Short description Item sequence number 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. Requirements Provides references to the claim items. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detailSequence		0..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.error.detailSequence Short description Detail sequence number 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. Requirements Provides references to the claim details within the claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subDetailSequence		0..1	positiveInt	There are no (further) constraints on this element Element id ClaimResponse.error.subDetailSequence Short description Subdetail sequence number 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. Requirements Provides references to the claim sub-details within the claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
code		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClaimResponse.error.code Short description Error code detailing processing issues Definition An error code, from a specified code system, which details why the claim could not be adjudicated. Requirements Required to convey processing errors. Data type CodeableConcept Binding The adjudication error codes. Adjudication Error Codes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`

Antwort auf Antrag Kostenübernahme

Feldname	Kurzbeschreibung
ClaimResponse.meta
ClaimResponse.meta.profile
ClaimResponse.extension
ClaimResponse.extension:Entscheidung	Entscheidung
ClaimResponse.status	Status der FHIR-Ressource
ClaimResponse.type	Kategorie des Antragstellers
ClaimResponse.use	Art des Kostenerstattungsantrags (claim, predetermination, preauthorization)
ClaimResponse.patient
ClaimResponse.created	Datum der Zusage / des Widerspruchs
ClaimResponse.insurer
ClaimResponse.request	Antrag
ClaimResponse.outcome	Ergebnis der Kostenübernahme

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-mtb-antwort-kostenuebernahme" />
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme" />
    <version value="2024.0.0-ballot" />
    <name value="MII_PR_MTB_Antwort_Kostenuebernahme" />
    <title value="MII PR MTB Anwort Kostenuebernahme" />
    <status value="draft" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Antwort auf Antrag Kosten&#252;bernahme" />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="ClaimResponse" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ClaimResponse" />
    <derivation value="constraint" />
    <differential>
        <element id="ClaimResponse.meta">
            <path value="ClaimResponse.meta" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.meta.profile">
            <path value="ClaimResponse.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.extension">
            <path value="ClaimResponse.extension" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.extension:Entscheidung">
            <path value="ClaimResponse.extension" />
            <sliceName value="Entscheidung" />
            <short value="Entscheidung" />
            <definition value="Stadium der Antwort auf den Antrag zur Kostenuebernahme" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.extension:Ablehnungsgrund">
            <path value="ClaimResponse.extension" />
            <sliceName value="Ablehnungsgrund" />
            <short value="Ablehnungsgrund" />
            <definition value="Stadium der Antwort auf den Antrag zur Kostenuebernahme" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund" />
            </type>
        </element>
        <element id="ClaimResponse.status">
            <path value="ClaimResponse.status" />
            <short value="Status der FHIR-Ressource" />
            <definition value="Status der FHIR-Ressource, statisch auf #active gesetzt, da retrospektive Datenerschlie&#223;ung" />
            <patternCode value="active" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.type">
            <path value="ClaimResponse.type" />
            <short value="Kategorie des Antragstellers" />
            <definition value="Kategorie des Antragstellers - z.B. station&#228;r, ambulant, Apotheke" />
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-antrag-kostenuebernahme" />
            </binding>
        </element>
        <element id="ClaimResponse.use">
            <path value="ClaimResponse.use" />
            <short value="Art des Kostenerstattungsantrags (claim, predetermination, preauthorization)" />
            <definition value="folgt den Definitionen wie im amerikanischen Gesundsheitswesen gebr&#228;uchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kosten&#252;bernahme;  preauthorization: Anfrage nach m&#246;glicher Erstattung f&#252;r zuk&#252;nftige Therapie" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.patient">
            <path value="ClaimResponse.patient" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.created">
            <path value="ClaimResponse.created" />
            <short value="Datum der Zusage / des Widerspruchs" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.insurer">
            <path value="ClaimResponse.insurer" />
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.request">
            <path value="ClaimResponse.request" />
            <short value="Antrag" />
            <definition value="Dazugeh&#246;riger Antrag zur Kosten&#252;bernahme" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antrag-kostenuebernahme" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClaimResponse.outcome">
            <path value="ClaimResponse.outcome" />
            <short value="Ergebnis der Kosten&#252;bernahme" />
            <definition value="Ergebnis der Kosten&#252;bernahme. F&#252;r den Fall der Sekund&#228;rdatenenutzung ist davon auszugehen, dass die Kostenerstattung bereits erfolgt ist. Daher ist der Status auf #complete gesetzt." />
            <patternCode value="complete" />
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-mtb-antwort-kostenuebernahme",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme",
    "version": "2024.0.0-ballot",
    "name": "MII_PR_MTB_Antwort_Kostenuebernahme",
    "title": "MII PR MTB Anwort Kostenuebernahme",
    "status": "draft",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Antwort auf Antrag Kostenübernahme",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "ClaimResponse",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "ClaimResponse.meta",
                "path": "ClaimResponse.meta",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.meta.profile",
                "path": "ClaimResponse.meta.profile",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.extension",
                "path": "ClaimResponse.extension",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.extension:Entscheidung",
                "path": "ClaimResponse.extension",
                "sliceName": "Entscheidung",
                "short": "Entscheidung",
                "definition": "Stadium der Antwort auf den Antrag zur Kostenuebernahme",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.extension:Ablehnungsgrund",
                "path": "ClaimResponse.extension",
                "sliceName": "Ablehnungsgrund",
                "short": "Ablehnungsgrund",
                "definition": "Stadium der Antwort auf den Antrag zur Kostenuebernahme",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund"
                        ]
                    }
                ]
            },
            {
                "id": "ClaimResponse.status",
                "path": "ClaimResponse.status",
                "short": "Status der FHIR-Ressource",
                "definition": "Status der FHIR-Ressource, statisch auf #active gesetzt, da retrospektive Datenerschließung",
                "patternCode": "active",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.type",
                "path": "ClaimResponse.type",
                "short": "Kategorie des Antragstellers",
                "definition": "Kategorie des Antragstellers - z.B. stationär, ambulant, Apotheke",
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-antrag-kostenuebernahme"
                }
            },
            {
                "id": "ClaimResponse.use",
                "path": "ClaimResponse.use",
                "short": "Art des Kostenerstattungsantrags (claim, predetermination, preauthorization)",
                "definition": "folgt den Definitionen wie im amerikanischen Gesundsheitswesen gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme;  preauthorization: Anfrage nach möglicher Erstattung für zukünftige Therapie",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.patient",
                "path": "ClaimResponse.patient",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.created",
                "path": "ClaimResponse.created",
                "short": "Datum der Zusage / des Widerspruchs",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.insurer",
                "path": "ClaimResponse.insurer",
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.request",
                "path": "ClaimResponse.request",
                "short": "Antrag",
                "definition": "Dazugehöriger Antrag zur Kostenübernahme",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antrag-kostenuebernahme"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClaimResponse.outcome",
                "path": "ClaimResponse.outcome",
                "short": "Ergebnis der Kostenübernahme",
                "definition": "Ergebnis der Kostenübernahme. Für den Fall der Sekundärdatenenutzung ist davon auszugehen, dass die Kostenerstattung bereits erfolgt ist. Daher ist der Status auf #complete gesetzt.",
                "patternCode": "complete",
                "mustSupport": true
            }
        ]
    }
}

MII PR MTB Anwort Kostenuebernahme

Mapping Datensatz zu FHIR

Datensatz	Erklaerung	FHIR
Datum	Datum	ClaimResponse.created
Antrag	Antrag	ClaimResponse.request
Status	Status	ClaimResponse.extension[Entscheidung]
Grund	Grund	ClaimResponse.extension[Ablehnungsgrund]

Suchparameter

Folgende Suchparameter sind für das Modul Onkologie relevant, auch in Kombination:

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?_id=12345

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "use" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?use=claim

Anwendungshinweise: Weitere Informationen zur Suche nach "ClaimResponse.use" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Der Suchparameter "patient" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?patient=Patient/example

Anwendungshinweise: Weitere Informationen zur Suche nach "ClaimResponse.patient" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "created" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?created=eq2022-01-01

Anwendungshinweise: Weitere Informationen zur Suche nach "ClaimResponse.created" finden sich in der FHIR-Basisspezifikation - Abschnitt "Date Search".
Der Suchparameter "request" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?request=MII_PR_MTB_Antrag_Kostenuebernahme/example

Anwendungshinweise: Weitere Informationen zur Suche nach "ClaimResponse.request" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "outcome" MUSS unterstützt werden:

Beispiele:

GET [base]/ClaimResponse?outcome=complete

Anwendungshinweise: Weitere Informationen zur Suche nach "ClaimResponse.outcome" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

Beispiele

Tabelle
JSON

ClaimResponse.id[0]	MII-EXA-MTB-Antwort-Kostenuebernahme-Beispiel-1
ClaimResponse.meta[0].profile[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme
ClaimResponse.extension[0].url[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung
ClaimResponse.extension[0].value[0].coding[0].system[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antwort-kostenuebernahme-entscheidung
ClaimResponse.extension[0].value[0].coding[0].code[0]	rejected
ClaimResponse.extension[1].url[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund
ClaimResponse.extension[1].value[0].coding[0].system[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antwort-kostenuebernahme-ablehnungsgrund
ClaimResponse.extension[1].value[0].coding[0].code[0]	other-therapy-recommended
ClaimResponse.status[0]	active
ClaimResponse.type[0].coding[0].code[0]	institutional
ClaimResponse.use[0]	claim
ClaimResponse.patient[0].reference[0]	Patient/example
ClaimResponse.created[0]	2024-07-07
ClaimResponse.insurer[0].reference[0]	Organization/InstitutionID
ClaimResponse.request[0].reference[0]	Claim/MII-EXA-MTB-Antrag-Kostenuebernahme-Beispiel-1
ClaimResponse.outcome[0]	complete

{
    "resourceType": "ClaimResponse",
    "id": "MII-EXA-MTB-Antwort-Kostenuebernahme-Beispiel-1",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-antwort-kostenuebernahme"
        ]
    },
    "extension":  [
        {
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "code": "rejected",
                        "system": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antwort-kostenuebernahme-entscheidung"
                    }
                ]
            },
            "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung"
        },
        {
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "code": "other-therapy-recommended",
                        "system": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-antwort-kostenuebernahme-ablehnungsgrund"
                    }
                ]
            },
            "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund"
        }
    ],
    "status": "active",
    "outcome": "complete",
    "type": {
        "coding":  [
            {
                "code": "institutional"
            }
        ]
    },
    "use": "claim",
    "patient": {
        "reference": "Patient/example"
    },
    "created": "2024-07-07",
    "insurer": {
        "reference": "Organization/InstitutionID"
    },
    "request": {
        "reference": "Claim/MII-EXA-MTB-Antrag-Kostenuebernahme-Beispiel-1"
    }
}