ClaimResponse

Defines the ID Core constraints and extensions on the ClaimResponse resource for the minimal set of data to query and retrieve claim information.

Usage

This profile is used by providers and payors, insurers, to exchange the financial information, and supporting clinical information, regarding the provision of health care services with payors and for verification status of claim.

The primary uses of this resource is to support verification of electronic claims, the exchange of information relating to the proposed or actual provision of healthcare-related goods and services for patients to their benefit payors, insurers and national health programs, for treatment payment planning and reimbursement.

URL

Type URL
Canonical https://fhir.kemkes.go.id/r4/StructureDefinition/ClaimResponse

Structure

Snapshot

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
identifier0..*Identifier
statusΣ ?!1..1codeBinding
typeΣ1..1CodeableConceptBinding
subType0..1CodeableConcept
useΣ1..1codeBinding
patientΣ C1..1Reference(Patient)
createdΣ1..1dateTime
insurerΣ C1..1Reference(Organization)
requestorC0..1Reference(Practitioner | PractitionerRole | Organization)
requestΣ C0..1Reference(Claim)
outcomeΣ1..1codeBinding
disposition0..1string
preAuthRef0..1string
preAuthPeriodC0..1Period
payeeType0..1CodeableConcept
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
itemSequence1..1positiveInt
noteNumber0..*positiveInt
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
category1..1CodeableConcept
reason0..1CodeableConcept
amount0..1Money
value0..1decimal
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
detailSequence1..1positiveInt
noteNumber0..*positiveInt
adjudication1..*see (adjudication)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
subDetailSequence1..1positiveInt
noteNumber0..*positiveInt
adjudication0..*see (adjudication)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
itemSequence0..*positiveInt
detailSequence0..*positiveInt
subdetailSequence0..*positiveInt
providerC0..*Reference(Practitioner | PractitionerRole | Organization)
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
programCode0..*CodeableConcept
servicedDatedate
servicedPeriodPeriod
locationCodeableConceptCodeableConcept
locationAddressAddress
locationReferenceReference(Location)
quantityC0..1https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
bodySite0..1CodeableConcept
subSite0..*CodeableConcept
noteNumber0..*positiveInt
adjudication1..*see (adjudication)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
quantityC0..1https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
noteNumber0..*positiveInt
adjudication1..*see (adjudication)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
productOrService1..1CodeableConcept
modifier0..*CodeableConcept
quantityC0..1https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
unitPrice0..1Money
factor0..1decimal
net0..1Money
noteNumber0..*positiveInt
adjudication1..*see (adjudication)
adjudication0..*see (adjudication)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
categoryΣ1..1CodeableConcept
amountΣ1..1Money
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
type1..1CodeableConcept
adjustment0..1Money
adjustmentReason0..1CodeableConcept
date0..1date
amount1..1Money
identifier0..1Identifier
fundsReserve0..1CodeableConcept
formCode0..1CodeableConcept
formC0..1Attachment
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
number0..1positiveInt
type0..1codeBinding
text1..1string
language0..1CodeableConceptBinding
communicationRequestC0..*Reference(https://fhir.kemkes.go.id/r4/StructureDefinition/CommunicationRequest)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
sequence1..1positiveInt
focal1..1boolean
coverageC1..1Reference(Coverage)
businessArrangement0..1string
claimResponseC0..1Reference(ClaimResponse)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
itemSequence0..1positiveInt
detailSequence0..1positiveInt
subDetailSequence0..1positiveInt
code1..1CodeableConcept

Examples

Dictionary

ClaimResponse
ShortResponse to a claim predetermination or preauthorization
Definition

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

Cardinality0..*
AliasRemittance Advice
Constraints
  • dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    contained.contained.empty()
  • dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
  • dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
  • dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    contained.meta.security.empty()
  • dom-6: A resource should have narrative for robust management
    text.`div`.exists()
Mappings
  • rim: Entity. Role, or Act
  • workflow: Event
ClaimResponse.id
ShortLogical id of this artifact
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Cardinality0..1
Typestring
SummaryTrue
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

ClaimResponse.meta
ShortMetadata about the resource
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Cardinality0..1
TypeMeta
SummaryTrue
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.implicitRules
ShortA set of rules under which this content was created
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Cardinality0..1
Typeuri
ModifierTrue
SummaryTrue
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.language
ShortLanguage of the resource content
Definition

The base language in which the resource is written.

Cardinality0..1
Typecode
Binding

A human language.

CommonLanguages (preferred)

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.text
ShortText summary of the resource, for human interpretation
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Cardinality0..1
TypeNarrative
Aliasnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: Act.text?
ClaimResponse.contained
ShortContained, inline Resources
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Cardinality0..*
TypeResource
Aliasinline resources, anonymous resources, contained resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Mappings
  • rim: N/A
ClaimResponse.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.modifierExtension
ShortExtensions that cannot be ignored
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
Aliasextensions, user content
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.identifier
ShortBusiness Identifier for a claim response
Definition

A unique identifier assigned to this claim response.

Cardinality0..*
TypeIdentifier
Requirements

Allows claim responses to be distinguished and referenced.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
  • workflow: Event.identifier
  • w5: FiveWs.identifier
ClaimResponse.status
Shortactive | cancelled | draft | entered-in-error
Definition

The status of the resource instance.

Cardinality1..1
Typecode
Binding

A code specifying the state of the resource instance.

FinancialResourceStatusCodes (required)

ModifierTrue
SummaryTrue
Requirements

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

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • workflow: Event.status
  • w5: FiveWs.status
ClaimResponse.type
ShortMore granular claim type
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

The type or discipline-style of the claim.

ClaimTypeCodes (extensible)

SummaryTrue
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • w5: FiveWs.class
ClaimResponse.subType
ShortMore granular claim type
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

A more granular claim typecode.

ExampleClaimSubTypeCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • w5: FiveWs.class
ClaimResponse.use
Shortclaim | preauthorization | predetermination
Definition

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

Cardinality1..1
Typecode
Binding

Claim, preauthorization, predetermination.

Use (required)

SummaryTrue
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • w5: FiveWs.class
ClaimResponse.patient
ShortThe recipient of the products and services
Definition

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

Cardinality1..1
TypeReference(Patient)
SummaryTrue
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.subject[x]
  • w5: FiveWs.subject
ClaimResponse.created
ShortResponse creation date
Definition

The date this resource was created.

Cardinality1..1
TypedateTime
SummaryTrue
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • workflow: Event.occurrence[x]
  • w5: FiveWs.recorded
ClaimResponse.insurer
ShortParty responsible for reimbursement
Definition

The party responsible for authorization, adjudication and reimbursement.

Cardinality1..1
TypeReference(Organization)
SummaryTrue
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow: Event.performer
ClaimResponse.requestor
ShortParty responsible for the claim
Definition

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

Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization)
Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.source
ClaimResponse.request
ShortId of resource triggering adjudication
Definition

Original request resource reference.

Cardinality0..1
TypeReference(Claim)
SummaryTrue
Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • workflow: Event.basedOn
  • w5: FiveWs.why[x]
ClaimResponse.outcome
Shortqueued | complete | error | partial
Definition

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

Cardinality1..1
Typecode
Binding

The result of the claim processing.

ClaimProcessingCodes (required)

SummaryTrue
Requirements

To advise the requestor of an overall processing outcome.

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.disposition
ShortDisposition Message
Definition

A human readable description of the status of the adjudication.

Cardinality0..1
Typestring
Requirements

Provided for user display.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • workflow: Event.note
ClaimResponse.preAuthRef
ShortPreauthorization reference
Definition

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

Cardinality0..1
Typestring
Requirements

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

Comments

This value is only present on preauthorization adjudications.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.preAuthPeriod
ShortPreauthorization reference effective period
Definition

The time frame during which this authorization is effective.

Cardinality0..1
TypePeriod
Requirements

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

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times").

Period is not used for a duration (a measure of elapsed time). See Duration.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • per-1: If present, start SHALL have a lower value than end
    start.hasValue().not() or end.hasValue().not() or (start <= end)
Mappings
  • rim: n/a
  • v2: DR
  • rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
ClaimResponse.payeeType
ShortParty to be paid any benefits payable
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

A code for the party to be reimbursed.

Claim Payee Type Codes (example)

Requirements

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

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.item
ShortAdjudication for claim line items
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

The adjudication for items provided on the claim.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.item.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.item.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.item.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.item.itemSequence
ShortClaim item instance identifier
Definition

A number to uniquely reference the claim item entries.

Cardinality1..1
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.adjudication
ShortAdjudication details
Definition

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

Cardinality1..*
TypeBackboneElement
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.item.adjudication.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.item.adjudication.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.item.adjudication.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.item.adjudication.category
ShortType of adjudication information
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

The adjudication codes.

AdjudicationValueCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.item.adjudication.reason
ShortExplanation of adjudication outcome
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

The adjudication reason codes.

AdjudicationReasonCodes (example)

Requirements

To support understanding of variance from adjudication expectations.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.item.adjudication.amount
ShortMonetary amount
Definition

Monetary amount associated with the category.

Cardinality0..1
TypeMoney
Requirements

Most adjuciation categories convey a monetary amount.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.item.adjudication.value
ShortNon-monetary value
Definition

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

Cardinality0..1
Typedecimal
Requirements

Some adjudication categories convey a percentage or a fixed value.

Comments

For example: eligible percentage or co-payment percentage.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.detail
ShortAdjudication for claim details
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

The adjudication for details provided on the claim.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.item.detail.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.item.detail.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.item.detail.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.item.detail.detailSequence
ShortClaim detail instance identifier
Definition

A number to uniquely reference the claim detail entry.

Cardinality1..1
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.detail.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.detail.adjudication
ShortDetail level adjudication details
Definition

The adjudication results.

Cardinality1..*
Typesee (adjudication)
ClaimResponse.item.detail.subDetail
ShortAdjudication for claim sub-details
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

The adjudication for sub-details provided on the claim.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.item.detail.subDetail.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.item.detail.subDetail.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.item.detail.subDetail.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.item.detail.subDetail.subDetailSequence
ShortClaim sub-detail instance identifier
Definition

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

Cardinality1..1
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.detail.subDetail.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.item.detail.subDetail.adjudication
ShortSubdetail level adjudication details
Definition

The adjudication results.

Cardinality0..*
Typesee (adjudication)
ClaimResponse.addItem
ShortInsurer added line items
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.addItem.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.addItem.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.addItem.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.addItem.itemSequence
ShortItem sequence number
Definition

Claim items which this service line is intended to replace.

Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim items.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.detailSequence
ShortDetail sequence number
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.subdetailSequence
ShortSubdetail sequence number
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.provider
ShortAuthorized providers
Definition

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

Cardinality0..*
TypeReference(Practitioner | PractitionerRole | Organization)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
  • w5: FiveWs.source
ClaimResponse.addItem.productOrService
ShortBilling, service, product, or drug code
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)

Requirements

Necessary to state what was provided or done.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.addItem.modifier
ShortService/Product billing modifiers
Definition

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

Cardinality0..*
TypeCodeableConcept
Binding

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ModifierTypeCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: 24.C, 24.D mods
ClaimResponse.addItem.programCode
ShortProgram the product or service is provided under
Definition

Identifies the program under which this may be recovered.

Cardinality0..*
TypeCodeableConcept
Binding

Program specific reason codes.

ExampleProgramReasonCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: 24.H
ClaimResponse.addItem.serviced[x]
ShortDate or dates of service or product delivery
Definition

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

Cardinality0..1
Typedate, Period
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.done[x]
  • rim: 24.A
ClaimResponse.addItem.location[x]
ShortPlace of service or where product was supplied
Definition

Where the product or service was provided.

Cardinality0..1
TypeCodeableConcept, Address, Reference(Location)
Binding

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

ExampleServicePlaceCodes (example)

Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • w5: FiveWs.where[x]
  • rim: 24.B
ClaimResponse.addItem.quantity
ShortCount of products or services
Definition

The number of repetitions of a service or product.

Cardinality0..1
Typehttps://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3: If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
Mappings
  • rim: n/a
  • v2: SN (see also Range) or CQ
  • rim: PQ, IVL<PQ>, MO, CO, depending on the values
  • rim: 24.G
ClaimResponse.addItem.unitPrice
ShortFee, charge or cost per item
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.addItem.factor
ShortPrice scaling factor
Definition

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

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.net
ShortTotal item cost
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
  • rim: 24.F
ClaimResponse.addItem.bodySite
ShortAnatomical location
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

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

OralSiteCodes (example)

Requirements

Allows insurer to validate specific procedures.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.addItem.subSite
ShortAnatomical sub-location
Definition

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

Cardinality0..*
TypeCodeableConcept
Binding

The code for the tooth surface and surface combinations.

SurfaceCodes (example)

Requirements

Allows insurer to validate specific procedures.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.addItem.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.adjudication
ShortAdded items adjudication
Definition

The adjudication results.

Cardinality1..*
Typesee (adjudication)
ClaimResponse.addItem.detail
ShortInsurer added line details
Definition

The second-tier service adjudications for payor added services.

Cardinality0..*
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.addItem.detail.productOrService
ShortBilling, service, product, or drug code
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)

Requirements

Necessary to state what was provided or done.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.addItem.detail.modifier
ShortService/Product billing modifiers
Definition

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

Cardinality0..*
TypeCodeableConcept
Binding

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ModifierTypeCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: 24.C, 24.D mods
ClaimResponse.addItem.detail.quantity
ShortCount of products or services
Definition

The number of repetitions of a service or product.

Cardinality0..1
Typehttps://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3: If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
Mappings
  • rim: n/a
  • v2: SN (see also Range) or CQ
  • rim: PQ, IVL<PQ>, MO, CO, depending on the values
  • rim: 24.G
ClaimResponse.addItem.detail.unitPrice
ShortFee, charge or cost per item
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.addItem.detail.factor
ShortPrice scaling factor
Definition

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

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.detail.net
ShortTotal item cost
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
  • rim: 24.F
ClaimResponse.addItem.detail.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.detail.adjudication
ShortAdded items detail adjudication
Definition

The adjudication results.

Cardinality1..*
Typesee (adjudication)
ClaimResponse.addItem.detail.subDetail
ShortInsurer added line items
Definition

The third-tier service adjudications for payor added services.

Cardinality0..*
TypeBackboneElement
ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.subDetail.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.subDetail.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.addItem.detail.subDetail.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.addItem.detail.subDetail.productOrService
ShortBilling, service, product, or drug code
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

Allowable service and product codes.

USCLSCodes (example)

Requirements

Necessary to state what was provided or done.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.addItem.detail.subDetail.modifier
ShortService/Product billing modifiers
Definition

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

Cardinality0..*
TypeCodeableConcept
Binding

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

ModifierTypeCodes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
  • rim: 24.C, 24.D mods
ClaimResponse.addItem.detail.subDetail.quantity
ShortCount of products or services
Definition

The number of repetitions of a service or product.

Cardinality0..1
Typehttps://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity
Requirements

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

Comments

The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • qty-3: If a code for the unit is present, the system SHALL also be present
    code.empty() or system.exists()
Mappings
  • rim: n/a
  • v2: SN (see also Range) or CQ
  • rim: PQ, IVL<PQ>, MO, CO, depending on the values
  • rim: 24.G
ClaimResponse.addItem.detail.subDetail.unitPrice
ShortFee, charge or cost per item
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.addItem.detail.subDetail.factor
ShortPrice scaling factor
Definition

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

Cardinality0..1
Typedecimal
Requirements

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

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.detail.subDetail.net
ShortTotal item cost
Definition

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

Cardinality0..1
TypeMoney
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
  • rim: 24.F
ClaimResponse.addItem.detail.subDetail.noteNumber
ShortApplicable note numbers
Definition

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

Cardinality0..*
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.addItem.detail.subDetail.adjudication
ShortAdded items detail adjudication
Definition

The adjudication results.

Cardinality1..*
Typesee (adjudication)
ClaimResponse.adjudication
ShortHeader-level adjudication
Definition

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

Cardinality0..*
Typesee (adjudication)
Requirements

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

ClaimResponse.total
ShortAdjudication totals
Definition

Categorized monetary totals for the adjudication.

Cardinality0..*
TypeBackboneElement
SummaryTrue
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.total.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.total.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.total.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.total.category
ShortType of adjudication information
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

The adjudication codes.

AdjudicationValueCodes (example)

SummaryTrue
Requirements

Needed to convey the type of total provided.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.total.amount
ShortFinancial total for the category
Definition

Monetary total amount associated with the category.

Cardinality1..1
TypeMoney
SummaryTrue
Requirements

Needed to convey the total monetary amount.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.payment
ShortPayment Details
Definition

Payment details for the adjudication of the claim.

Cardinality0..1
TypeBackboneElement
Requirements

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.payment.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.payment.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.payment.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.payment.type
ShortPartial or complete payment
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

The type (partial, complete) of the payment.

ExamplePaymentTypeCodes (example)

Requirements

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

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.payment.adjustment
ShortPayment adjustment for non-claim issues
Definition

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

Cardinality0..1
TypeMoney
Requirements

To advise the requestor of adjustments applied to the payment.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.payment.adjustmentReason
ShortExplanation for the adjustment
Definition

Reason for the payment adjustment.

Cardinality0..1
TypeCodeableConcept
Binding

Payment Adjustment reason codes.

PaymentAdjustmentReasonCodes (example)

Requirements

Needed to clarify the monetary adjustment.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.payment.date
ShortExpected date of payment
Definition

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

Cardinality0..1
Typedate
Requirements

To advise the payee when payment can be expected.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.payment.amount
ShortPayable amount after adjustment
Definition

Benefits payable less any payment adjustment.

Cardinality1..1
TypeMoney
Requirements

Needed to provide the actual payment amount.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: MO
ClaimResponse.payment.identifier
ShortBusiness identifier for the payment
Definition

Issuer's unique identifier for the payment instrument.

Cardinality0..1
TypeIdentifier
Requirements

Enable the receiver to reconcile when payment received.

Comments

For example: EFT number or check number.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
  • rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
  • servd: Identifier
ClaimResponse.fundsReserve
ShortFunds reserved status
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

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

Funds Reservation Codes (example)

Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.formCode
ShortPrinted form identifier
Definition

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

Cardinality0..1
TypeCodeableConcept
Binding

The forms codes.

Form Codes (example)

Requirements

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

Comments

May be needed to identify specific jurisdictional forms.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.form
ShortPrinted reference or actual form
Definition

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

Cardinality0..1
TypeAttachment
Requirements

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

Comments

Needed to permit insurers to include the actual form.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • att-1: If the Attachment has data, it SHALL have a contentType
    data.empty() or contentType.exists()
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: ED/RP
  • rim: ED
ClaimResponse.processNote
ShortNote concerning adjudication
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

Provides the insurer specific textual explanations associated with the processing.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.processNote.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.processNote.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.processNote.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.processNote.number
ShortNote instance identifier
Definition

A number to uniquely identify a note entry.

Cardinality0..1
TypepositiveInt
Requirements

Necessary to provide a mechanism to link from adjudications.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.processNote.type
Shortdisplay | print | printoper
Definition

The business purpose of the note text.

Cardinality0..1
Typecode
Binding

The presentation types of notes.

NoteType (required)

Requirements

To convey the expectation for when the text is used.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.processNote.text
ShortNote explanatory text
Definition

The explanation or description associated with the processing.

Cardinality1..1
Typestring
Requirements

Required to provide human readable explanation.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.processNote.language
ShortLanguage of the text
Definition

A code to define the language used in the text of the note.

Cardinality0..1
TypeCodeableConcept
Binding

A human language.

CommonLanguages (preferred)

Requirements

Note text may vary from the resource defined language.

Comments

Only required if the language is different from the resource language.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
ClaimResponse.communicationRequest
ShortRequest for additional information
Definition

Request for additional supporting or authorizing information.

Cardinality0..*
TypeReference(https://fhir.kemkes.go.id/r4/StructureDefinition/CommunicationRequest)
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
ClaimResponse.insurance
ShortPatient insurance information
Definition

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

Cardinality0..*
TypeBackboneElement
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • rim: Coverage
ClaimResponse.insurance.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.insurance.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.insurance.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.insurance.sequence
ShortInsurance instance identifier
Definition

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

Cardinality1..1
TypepositiveInt
Requirements

To maintain order of the coverages.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.insurance.focal
ShortCoverage to be used for adjudication
Definition

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

Cardinality1..1
Typeboolean
Requirements

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

Comments

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.insurance.coverage
ShortInsurance information
Definition

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

Cardinality1..1
TypeReference(Coverage)
Requirements

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

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
ClaimResponse.insurance.businessArrangement
ShortAdditional provider contract number
Definition

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

Cardinality0..1
Typestring
Requirements

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

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.insurance.claimResponse
ShortAdjudication results
Definition

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

Cardinality0..1
TypeReference(ClaimResponse)
Requirements

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

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ref-1: SHALL have a contained resource if a local reference is provided
    reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
Mappings
  • rim: n/a
  • rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
ClaimResponse.error
ShortProcessing errors
Definition

Errors encountered during the processing of the adjudication.

Cardinality0..*
TypeBackboneElement
Requirements

Need to communicate processing issues to the requestor.

Comments

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

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
ClaimResponse.error.id
ShortUnique id for inter-element referencing
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Cardinality0..1
Typestring
Mappings
  • rim: n/a
ClaimResponse.error.extension
ShortAdditional content defined by implementations
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Cardinality0..*
TypeExtension
Aliasextensions, user content
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: n/a
ClaimResponse.error.modifierExtension
ShortExtensions that cannot be ignored even if unrecognized
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Cardinality0..*
TypeExtension
ModifierTrue
SummaryTrue
Aliasextensions, user content, modifiers
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
  • ext-1: Must have either extensions or value[x], not both
    extension.exists() != value.exists()
Mappings
  • rim: N/A
ClaimResponse.error.itemSequence
ShortItem sequence number
Definition

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

Cardinality0..1
TypepositiveInt
Requirements

Provides references to the claim items.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.error.detailSequence
ShortDetail sequence number
Definition

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

Cardinality0..1
TypepositiveInt
Requirements

Provides references to the claim details within the claim item.

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.error.subDetailSequence
ShortSubdetail sequence number
Definition

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

Cardinality0..1
TypepositiveInt
Requirements

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

Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
ClaimResponse.error.code
ShortError code detailing processing issues
Definition

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

Cardinality1..1
TypeCodeableConcept
Binding

The adjudication error codes.

Adjudication Error Codes (example)

Requirements

Required to convey processing errors.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1
Constraints
  • ele-1: All FHIR elements must have a @value or children
    hasValue() or (children().count() > id.count())
Mappings
  • rim: n/a
  • v2: CE/CNE/CWE
  • rim: CD
  • orim: fhir:CodeableConcept rdfs:subClassOf dt:CD