Dieses Profil beschreibt Informationen über den praktischen Vorgang "Follow-Up" und dessen Status.
Name | Status | Version | Canonical | Basis |
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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 |
MII_PR_MTB_Antwort_Kostenuebernahme (ClaimResponse) | I | ClaimResponse | There are no (further) constraints on this element Element idClaimResponse Response to a claim predetermination or preauthorization Alternate namesRemittance Advice DefinitionThis resource provides the adjudication details from the processing of a Claim resource.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idClaimResponse.meta Metadata about the resource DefinitionThe 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.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idClaimResponse.implicitRules A set of rules under which this content was created DefinitionA 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. 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.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idClaimResponse.language Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idClaimResponse.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idClaimResponse.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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extension | I | 0..* | Extension | Element idClaimResponse.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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Entscheidung | S I | 0..1 | Extension(CodeableConcept) | Element idClaimResponse.extension:Entscheidung Entscheidung Alternate namesextensions, user content DefinitionStadium der Antwort auf den Antrag zur Kostenuebernahme 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.
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Ablehnungsgrund | I | 0..1 | Extension(CodeableConcept) | Element idClaimResponse.extension:Ablehnungsgrund Ablehnungsgrund Alternate namesextensions, user content DefinitionStadium der Antwort auf den Antrag zur Kostenuebernahme 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.
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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.
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identifier | 0..* | Identifier | There are no (further) constraints on this element Element idClaimResponse.identifier Business Identifier for a claim response DefinitionA unique identifier assigned to this claim response. Allows claim responses to be distinguished and referenced.
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status | S Σ ?! | 1..1 | codeBindingPattern | Element idClaimResponse.status Status der FHIR-Ressource DefinitionStatus der FHIR-Ressource, statisch auf #active gesetzt, da retrospektive Datenerschließung 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'. This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. A code specifying the state of the resource instance.
active
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type | S Σ | 1..1 | CodeableConceptBinding | Element idClaimResponse.type Kategorie des Antragstellers DefinitionKategorie des Antragstellers - z.B. stationär, ambulant, Apotheke Some jurisdictions need a finer grained claim type for routing and adjudication. This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. The type or discipline-style of the claim.
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subType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.subType More granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Some jurisdictions need a finer grained claim type for routing and adjudication. This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. A more granular claim typecode.
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use | S Σ | 1..1 | codeBinding | Element idClaimResponse.use Art des Kostenerstattungsantrags (claim, predetermination, preauthorization) Definitionfolgt 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 This element is required to understand the nature of the request for adjudication. Claim, preauthorization, predetermination.
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patient | S Σ | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idClaimResponse.patient The recipient of the products and services DefinitionThe 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. 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.
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created | S Σ | 1..1 | dateTime | Element idClaimResponse.created Datum der Zusage / des Widerspruchs DefinitionThe date this resource was created. Need to record a timestamp for use by both the recipient and the issuer.
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insurer | S Σ | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idClaimResponse.insurer Party responsible for reimbursement DefinitionThe party responsible for authorization, adjudication and reimbursement. 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.
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requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idClaimResponse.requestor Party responsible for the claim DefinitionThe provider which is responsible for the claim, predetermination or preauthorization. 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. Reference(Practitioner | PractitionerRole | Organization) Constraints
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request | S Σ | 0..1 | Reference(MII_PR_MTB_Antrag_Kostenuebernahme) | Element idClaimResponse.request Antrag DefinitionDazugehöriger Antrag zur Kostenübernahme Reference(MII_PR_MTB_Antrag_Kostenuebernahme) Constraints
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outcome | S Σ | 1..1 | codeBindingPattern | Element idClaimResponse.outcome queued | complete | error | partial DefinitionThe outcome of the claim, predetermination, or preauthorization processing. To advise the requestor of an overall processing outcome. 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). The result of the claim processing.
complete |
disposition | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.disposition Disposition Message DefinitionA human readable description of the status of the adjudication. Provided for user display.
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preAuthRef | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.preAuthRef Preauthorization reference DefinitionReference from the Insurer which is used in later communications which refers to this adjudication. On subsequent claims, the insurer may require the provider to quote this value. This value is only present on preauthorization adjudications.
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preAuthPeriod | 0..1 | Period | There are no (further) constraints on this element Element idClaimResponse.preAuthPeriod Preauthorization reference effective period DefinitionThe time frame during which this authorization is effective. To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
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payeeType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payeeType Party to be paid any benefits payable DefinitionType of Party to be reimbursed: subscriber, provider, other. Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. A code for the party to be reimbursed.
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item | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item Adjudication for claim line items DefinitionA 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. The adjudication for items provided on the claim.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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itemSequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.itemSequence Claim item instance identifier DefinitionA number to uniquely reference the claim item entries. Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 1..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.adjudication Adjudication details DefinitionIf 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. The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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category | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.category Type of adjudication information DefinitionA 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. Needed to enable understanding of the context of the other information in the adjudication. For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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reason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.reason Explanation of adjudication outcome DefinitionA code supporting the understanding of the adjudication result and explaining variance from expected amount. To support understanding of variance from adjudication expectations. For example may indicate that the funds for this benefit type have been exhausted. The adjudication reason codes.
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amount | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.amount Monetary amount DefinitionMonetary amount associated with the category. Most adjuciation categories convey a monetary amount. For example: amount submitted, eligible amount, co-payment, and benefit payable.
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value | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.value Non-monetary value DefinitionA non-monetary value associated with the category. Mutually exclusive to the amount element above. Some adjudication categories convey a percentage or a fixed value. For example: eligible percentage or co-payment percentage.
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detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.detail Adjudication for claim details DefinitionA claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items. The adjudication for details provided on the claim.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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detailSequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.detailSequence Claim detail instance identifier DefinitionA number to uniquely reference the claim detail entry. Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 1..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.item.detail.adjudication Detail level adjudication details DefinitionThe adjudication results.
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subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail Adjudication for claim sub-details DefinitionA sub-detail adjudication of a simple product or service. The adjudication for sub-details provided on the claim.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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subDetailSequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.subDetailSequence Claim sub-detail instance identifier DefinitionA number to uniquely reference the claim sub-detail entry. Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.adjudication Subdetail level adjudication details DefinitionThe adjudication results.
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addItem | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem Insurer added line items DefinitionThe first-tier service adjudications for payor added product or service lines. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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itemSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.itemSequence Item sequence number DefinitionClaim items which this service line is intended to replace. Provides references to the claim items.
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detailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detailSequence Detail sequence number DefinitionThe sequence number of the details within the claim item which this line is intended to replace. Provides references to the claim details within the claim item.
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subdetailSequence | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.subdetailSequence Subdetail sequence number DefinitionThe sequence number of the sub-details within the details within the claim item which this line is intended to replace. Provides references to the claim sub-details within the claim detail.
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provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idClaimResponse.addItem.provider Authorized providers DefinitionThe providers who are authorized for the services rendered to the patient. Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. Reference(Practitioner | PractitionerRole | Organization) Constraints
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.productOrService Billing, service, product, or drug code DefinitionWhen 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. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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programCode | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.programCode Program the product or service is provided under DefinitionIdentifies the program under which this may be recovered. Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. For example: Neonatal program, child dental program or drug users recovery program. Program specific reason codes.
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serviced[x] | 0..1 | There are no (further) constraints on this element Element idClaimResponse.addItem.serviced[x] Date or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed. Needed to determine whether the service or product was provided during the term of the insurance coverage.
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servicedDate | date | There are no (further) constraints on this element Data type | ||
servicedPeriod | Period | There are no (further) constraints on this element Data type | ||
location[x] | 0..1 | There are no (further) constraints on this element Element idClaimResponse.addItem.location[x] Place of service or where product was supplied DefinitionWhere the product or service was provided. The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Place of service: pharmacy, school, prison, etc.
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locationCodeableConcept | CodeableConcept | There are no (further) constraints on this element Data type | ||
locationAddress | Address | There are no (further) constraints on this element Data type | ||
locationReference | Reference(Location) | There are no (further) constraints on this element Data type | ||
quantity | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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bodySite | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.bodySite Anatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.). Allows insurer to validate specific procedures. For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. The code for the teeth, quadrant, sextant and arch.
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subSite | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.subSite Anatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s). Allows insurer to validate specific procedures. The code for the tooth surface and surface combinations.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 1..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.addItem.adjudication Added items adjudication DefinitionThe adjudication results.
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detail | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem.detail Insurer added line details DefinitionThe second-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.productOrService Billing, service, product, or drug code DefinitionWhen 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. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 1..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.adjudication Added items detail adjudication DefinitionThe adjudication results.
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subDetail | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail Insurer added line items DefinitionThe third-tier service adjudications for payor added services.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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productOrService | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.productOrService Billing, service, product, or drug code DefinitionWhen 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. Necessary to state what was provided or done. 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'. Allowable service and product codes.
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modifier | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.modifier Service/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service. To support inclusion of the item for adjudication or to charge an elevated fee. 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. Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
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quantity | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.quantity Count of products or services DefinitionThe number of repetitions of a service or product. Required when the product or service code does not convey the quantity provided.
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unitPrice | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.unitPrice Fee, charge or cost per item DefinitionIf 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. The amount charged to the patient by the provider for a single unit.
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factor | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.factor Price scaling factor DefinitionA 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. When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
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net | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.net Total item cost DefinitionThe quantity times the unit price for an additional service or product or charge. Provides the total amount claimed for the group (if a grouper) or the line item. For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
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noteNumber | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.noteNumber Applicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item. Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
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adjudication | 1..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.adjudication Added items detail adjudication DefinitionThe adjudication results.
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adjudication | 0..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.adjudication Header-level adjudication DefinitionThe adjudication results which are presented at the header level rather than at the line-item or add-item levels. Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
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total | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.total Adjudication totals DefinitionCategorized monetary totals for the adjudication. To provide the requestor with financial totals by category for the adjudication. Totals for amounts submitted, co-pays, benefits payable etc.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.total.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.total.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.total.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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category | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.total.category Type of adjudication information DefinitionA 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. Needed to convey the type of total provided. For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. The adjudication codes.
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amount | Σ | 1..1 | Money | There are no (further) constraints on this element Element idClaimResponse.total.amount Financial total for the category DefinitionMonetary total amount associated with the category. Needed to convey the total monetary amount.
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payment | 0..1 | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.payment Payment Details DefinitionPayment details for the adjudication of the claim. Needed to convey references to the financial instrument that has been used if payment has been made.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.payment.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.payment.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.payment.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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type | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payment.type Partial or complete payment DefinitionWhether this represents partial or complete payment of the benefits payable. To advise the requestor when the insurer believes all payments to have been completed. The type (partial, complete) of the payment.
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adjustment | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.payment.adjustment Payment adjustment for non-claim issues DefinitionTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. To advise the requestor of adjustments applied to the payment. 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.
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adjustmentReason | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payment.adjustmentReason Explanation for the adjustment DefinitionReason for the payment adjustment. Needed to clarify the monetary adjustment. Payment Adjustment reason codes.
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date | 0..1 | date | There are no (further) constraints on this element Element idClaimResponse.payment.date Expected date of payment DefinitionEstimated date the payment will be issued or the actual issue date of payment. To advise the payee when payment can be expected.
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amount | 1..1 | Money | There are no (further) constraints on this element Element idClaimResponse.payment.amount Payable amount after adjustment DefinitionBenefits payable less any payment adjustment. Needed to provide the actual payment amount.
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identifier | 0..1 | Identifier | There are no (further) constraints on this element Element idClaimResponse.payment.identifier Business identifier for the payment DefinitionIssuer's unique identifier for the payment instrument. Enable the receiver to reconcile when payment received. For example: EFT number or check number.
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fundsReserve | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.fundsReserve Funds reserved status DefinitionA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. For whom funds are to be reserved: (Patient, Provider, None).
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formCode | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.formCode Printed form identifier DefinitionA code for the form to be used for printing the content. Needed to specify the specific form used for producing output for this response. May be needed to identify specific jurisdictional forms. The forms codes.
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form | 0..1 | Attachment | There are no (further) constraints on this element Element idClaimResponse.form Printed reference or actual form DefinitionThe actual form, by reference or inclusion, for printing the content or an EOB. Needed to include the specific form used for producing output for this response. Needed to permit insurers to include the actual form.
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processNote | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.processNote Note concerning adjudication DefinitionA note that describes or explains adjudication results in a human readable form. Provides the insurer specific textual explanations associated with the processing.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.processNote.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.processNote.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.processNote.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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number | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.processNote.number Note instance identifier DefinitionA number to uniquely identify a note entry. Necessary to provide a mechanism to link from adjudications.
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type | 0..1 | codeBinding | There are no (further) constraints on this element Element idClaimResponse.processNote.type display | print | printoper DefinitionThe business purpose of the note text. To convey the expectation for when the text is used. The presentation types of notes.
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text | 1..1 | string | There are no (further) constraints on this element Element idClaimResponse.processNote.text Note explanatory text DefinitionThe explanation or description associated with the processing. Required to provide human readable explanation.
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language | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idClaimResponse.processNote.language Language of the text DefinitionA code to define the language used in the text of the note. Note text may vary from the resource defined language. Only required if the language is different from the resource language. A human language.
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communicationRequest | 0..* | Reference(CommunicationRequest) | There are no (further) constraints on this element Element idClaimResponse.communicationRequest Request for additional information DefinitionRequest for additional supporting or authorizing information. Need to communicate insurer request for additional information required to support the adjudication. For example: professional reports, documents, images, clinical resources, or accident reports. Reference(CommunicationRequest) Constraints
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insurance | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.insurance Patient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim. At least one insurer is required for a claim to be a claim. 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.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.insurance.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.insurance.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.insurance.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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sequence | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.insurance.sequence Insurance instance identifier DefinitionA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. To maintain order of the coverages.
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focal | 1..1 | boolean | There are no (further) constraints on this element Element idClaimResponse.insurance.focal Coverage to be used for adjudication DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. To identify which coverage in the list is being used to adjudicate this claim. 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.
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coverage | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idClaimResponse.insurance.coverage Insurance information DefinitionReference 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. Required to allow the adjudicator to locate the correct policy and history within their information system.
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businessArrangement | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.insurance.businessArrangement Additional provider contract number DefinitionA business agreement number established between the provider and the insurer for special business processing purposes. Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
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claimResponse | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idClaimResponse.insurance.claimResponse Adjudication results DefinitionThe result of the adjudication of the line items for the Coverage specified in this insurance. An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim. Must not be specified when 'focal=true' for this insurance.
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error | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.error Processing errors DefinitionErrors encountered during the processing of the adjudication. Need to communicate processing issues to the requestor. If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
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id | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.error.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.error.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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.
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.error.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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itemSequence | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.itemSequence Item sequence number DefinitionThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. Provides references to the claim items.
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detailSequence | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.detailSequence Detail sequence number DefinitionThe 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. Provides references to the claim details within the claim item.
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subDetailSequence | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.subDetailSequence Subdetail sequence number DefinitionThe 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. Provides references to the claim sub-details within the claim detail.
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code | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.error.code Error code detailing processing issues DefinitionAn error code, from a specified code system, which details why the claim could not be adjudicated. Required to convey processing errors. The adjudication error codes.
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Antwort auf Antrag Kostenübernahme |
Feldname | Kurzbeschreibung |
---|---|
ClaimResponse.meta | |
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 |
<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 Kostenübernahme" /> <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.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 Datenerschließung" /> <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. stationär, 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 gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme; preauthorization: Anfrage nach möglicher Erstattung für zukünftige 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="Dazugehöriger Antrag zur Kostenübernahme" /> <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" /> <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.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", "patternCode": "complete", "mustSupport": true } ] } }
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]/CarePlan?_id=12345
Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Beispiele
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