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

ClaimResponse	C		DomainResource	Element id ClaimResponse Short description Response to a claim predetermination or preauthorization Alternate names Remittance Advice Definition This resource provides the adjudication details from the processing of a Claim resource. Data type DomainResource Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event
id	Σ	0..1	string	There are no (further) constraints on this element Element id ClaimResponse.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id ClaimResponse.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id ClaimResponse.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id ClaimResponse.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id ClaimResponse.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id ClaimResponse.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
identifier		0..*	Identifier	Element id ClaimResponse.identifier Short description Business Identifier for a claim response Definition A unique identifier assigned to this claim response. Requirements Allows claim responses to be distinguished and referenced. Data type Identifier Conditions The 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
status	Σ ?!	1..1	codeBinding	Element id ClaimResponse.status Short description active \| cancelled \| draft \| entered-in-error Definition The status of the resource instance. Requirements Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding A code specifying the state of the resource instance. FinancialResourceStatusCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status
type	Σ	1..1	CodeableConceptBinding	Element id ClaimResponse.type Short description More granular claim type Definition A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Requirements Some jurisdictions need a finer grained claim type for routing and adjudication. Comments This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. Data type CodeableConcept Binding The type or discipline-style of the claim. ClaimTypeCodes (extensible) Conditions The 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
subType		0..1	CodeableConcept	Element id ClaimResponse.subType Short description More granular claim type Definition A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. Requirements Some jurisdictions need a finer grained claim type for routing and adjudication. Comments This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. Data type CodeableConcept Binding A more granular claim typecode. ExampleClaimSubTypeCodes (example) Conditions The 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
use	Σ	1..1	codeBinding	Element id ClaimResponse.use Short description claim \| 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. Requirements This element is required to understand the nature of the request for adjudication. Data type code Binding Claim, preauthorization, predetermination. Use (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class
patient	Σ C	1..1	Reference(Patient)	Element id ClaimResponse.patient Short description The recipient of the products and services Definition The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought. Requirements The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction. 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. Data type Reference(Patient) Conditions The 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
created	Σ	1..1	dateTime	Element id ClaimResponse.created Short description Response creation date Definition The date this resource was created. Requirements Need to record a timestamp for use by both the recipient and the issuer. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.recorded
insurer	Σ C	1..1	Reference(Organization)	Element id ClaimResponse.insurer Short description Party responsible for reimbursement Definition The party responsible for authorization, adjudication and reimbursement. Requirements To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. 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. Data type Reference(Organization) Conditions The 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
requestor	C	0..1	Reference(Practitioner \| PractitionerRole \| Organization)	Element id ClaimResponse.requestor Short description Party responsible for the claim Definition The provider which is responsible for the claim, predetermination or preauthorization. Comments Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. Data type Reference(Practitioner \| PractitionerRole \| Organization) Conditions The 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
request	Σ C	0..1	Reference(Claim)	Element id ClaimResponse.request Short description Id of resource triggering adjudication Definition Original request resource reference. 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. Data type Reference(Claim) Conditions The 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]
outcome	Σ	1..1	codeBinding	Element id ClaimResponse.outcome Short description queued \| complete \| error \| partial Definition The outcome of the claim, predetermination, or preauthorization processing. Requirements To advise the requestor of an overall processing outcome. Comments The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). Data type code Binding The result of the claim processing. ClaimProcessingCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
disposition		0..1	string	Element id ClaimResponse.disposition Short description Disposition Message Definition A human readable description of the status of the adjudication. Requirements Provided for user display. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.note
preAuthRef		0..1	string	Element id ClaimResponse.preAuthRef Short description Preauthorization reference Definition Reference from the Insurer which is used in later communications which refers to this adjudication. Requirements On subsequent claims, the insurer may require the provider to quote this value. Comments This value is only present on preauthorization adjudications. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
preAuthPeriod	C	0..1	Period	Element id ClaimResponse.preAuthPeriod Short description Preauthorization reference effective period Definition The time frame during which this authorization is effective. Requirements To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply. 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. Data type Period Conditions The 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"]
payeeType		0..1	CodeableConcept	Element id ClaimResponse.payeeType Short description Party to be paid any benefits payable Definition Type of Party to be reimbursed: subscriber, provider, other. Requirements Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. 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. Data type CodeableConcept Binding A code for the party to be reimbursed. Claim Payee Type Codes (example) Conditions The 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
item		0..*	BackboneElement	Element id ClaimResponse.item Short description Adjudication for claim line items Definition A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. Requirements The adjudication for items provided on the claim. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		1..1	positiveInt	Element id ClaimResponse.item.itemSequence Short description Claim item instance identifier Definition A number to uniquely reference the claim item entries. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	Element id ClaimResponse.item.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	BackboneElement	Element id ClaimResponse.item.adjudication Short description Adjudication details Definition If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. Requirements The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.adjudication.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
category		1..1	CodeableConcept	Element id ClaimResponse.item.adjudication.category Short description Type of adjudication information Definition A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item. Requirements Needed to enable understanding of the context of the other information in the adjudication. Comments For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Data type CodeableConcept Binding The adjudication codes. AdjudicationValueCodes (example) Conditions The 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
reason		0..1	CodeableConcept	Element id ClaimResponse.item.adjudication.reason Short description Explanation of adjudication outcome Definition A code supporting the understanding of the adjudication result and explaining variance from expected amount. Requirements To support understanding of variance from adjudication expectations. Comments For example may indicate that the funds for this benefit type have been exhausted. Data type CodeableConcept Binding The adjudication reason codes. AdjudicationReasonCodes (example) Conditions The 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
amount		0..1	Money	Element id ClaimResponse.item.adjudication.amount Short description Monetary amount Definition Monetary amount associated with the category. Requirements Most adjuciation categories convey a monetary amount. Comments For example: amount submitted, eligible amount, co-payment, and benefit payable. Data type Money Conditions The 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
value		0..1	decimal	Element id ClaimResponse.item.adjudication.value Short description Non-monetary value Definition A non-monetary value associated with the category. Mutually exclusive to the amount element above. Requirements Some adjudication categories convey a percentage or a fixed value. Comments For example: eligible percentage or co-payment percentage. Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detail		0..*	BackboneElement	Element id ClaimResponse.item.detail Short description Adjudication for claim details Definition A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items. Requirements The adjudication for details provided on the claim. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.detail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
detailSequence		1..1	positiveInt	Element id ClaimResponse.item.detail.detailSequence Short description Claim detail instance identifier Definition A number to uniquely reference the claim detail entry. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	Element id ClaimResponse.item.detail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.item.detail.adjudication Short description Detail level adjudication details Definition The adjudication results.
subDetail		0..*	BackboneElement	Element id ClaimResponse.item.detail.subDetail Short description Adjudication for claim sub-details Definition A sub-detail adjudication of a simple product or service. Requirements The adjudication for sub-details provided on the claim. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
subDetailSequence		1..1	positiveInt	Element id ClaimResponse.item.detail.subDetail.subDetailSequence Short description Claim sub-detail instance identifier Definition A number to uniquely reference the claim sub-detail entry. Requirements Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
noteNumber		0..*	positiveInt	Element id ClaimResponse.item.detail.subDetail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		0..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.item.detail.subDetail.adjudication Short description Subdetail level adjudication details Definition The adjudication results.
addItem		0..*	BackboneElement	Element id ClaimResponse.addItem Short description Insurer added line items Definition The first-tier service adjudications for payor added product or service lines. Requirements Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		0..*	positiveInt	Element id ClaimResponse.addItem.itemSequence Short description Item sequence number Definition Claim items which this service line is intended to replace. Requirements Provides references to the claim items. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detailSequence		0..*	positiveInt	Element id ClaimResponse.addItem.detailSequence Short description Detail sequence number Definition The sequence number of the details within the claim item which this line is intended to replace. Requirements Provides references to the claim details within the claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subdetailSequence		0..*	positiveInt	Element id ClaimResponse.addItem.subdetailSequence Short description Subdetail sequence number Definition The sequence number of the sub-details within the details within the claim item which this line is intended to replace. Requirements Provides references to the claim sub-details within the claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
provider	C	0..*	Reference(Practitioner \| PractitionerRole \| Organization)	Element id ClaimResponse.addItem.provider Short description Authorized providers Definition The providers who are authorized for the services rendered to the patient. Requirements Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. 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. Data type Reference(Practitioner \| PractitionerRole \| Organization) Conditions The 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
productOrService		1..1	CodeableConcept	Element id ClaimResponse.addItem.productOrService Short description Billing, service, product, or drug code Definition When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Requirements Necessary to state what was provided or done. Comments If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Conditions The 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
modifier		0..*	CodeableConcept	Element id ClaimResponse.addItem.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Conditions The 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
programCode		0..*	CodeableConcept	Element id ClaimResponse.addItem.programCode Short description Program the product or service is provided under Definition Identifies the program under which this may be recovered. Requirements Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. Comments For example: Neonatal program, child dental program or drug users recovery program. Data type CodeableConcept Binding Program specific reason codes. ExampleProgramReasonCodes (example) Conditions The 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
serviced[x]		0..1		Element id ClaimResponse.addItem.serviced[x] Short description Date or dates of service or product delivery Definition The date or dates when the service or product was supplied, performed or completed. Requirements Needed to determine whether the service or product was provided during the term of the insurance coverage. Conditions The 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
servicedDate			date	Data type date
servicedPeriod			Period	Data type Period
location[x]		0..1		Element id ClaimResponse.addItem.location[x] Short description Place of service or where product was supplied Definition Where the product or service was provided. Requirements The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. Binding Place of service: pharmacy, school, prison, etc. ExampleServicePlaceCodes (example) Conditions The 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
locationCodeableConcept			CodeableConcept	Data type CodeableConcept
locationAddress			Address	Data type Address
locationReference			Reference(Location)	Data type Reference(Location)
quantity	C	0..1	https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity	Element id ClaimResponse.addItem.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. 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. Data type https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity Conditions The 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
unitPrice		0..1	Money	Element id ClaimResponse.addItem.unitPrice Short description Fee, charge or cost per item Definition If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Conditions The 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
factor		0..1	decimal	Element id ClaimResponse.addItem.factor Short description Price scaling factor Definition A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	Element id ClaimResponse.addItem.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Conditions The 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
bodySite		0..1	CodeableConcept	Element id ClaimResponse.addItem.bodySite Short description Anatomical location Definition Physical service site on the patient (limb, tooth, etc.). Requirements Allows insurer to validate specific procedures. Comments For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. Data type CodeableConcept Binding The code for the teeth, quadrant, sextant and arch. OralSiteCodes (example) Conditions The 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
subSite		0..*	CodeableConcept	Element id ClaimResponse.addItem.subSite Short description Anatomical sub-location Definition A region or surface of the bodySite, e.g. limb region or tooth surface(s). Requirements Allows insurer to validate specific procedures. 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. Data type CodeableConcept Binding The code for the tooth surface and surface combinations. SurfaceCodes (example) Conditions The 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
noteNumber		0..*	positiveInt	Element id ClaimResponse.addItem.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.adjudication Short description Added items adjudication Definition The adjudication results.
detail		0..*	BackboneElement	Element id ClaimResponse.addItem.detail Short description Insurer added line details Definition The second-tier service adjudications for payor added services. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
productOrService		1..1	CodeableConcept	Element id ClaimResponse.addItem.detail.productOrService Short description Billing, service, product, or drug code Definition When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Requirements Necessary to state what was provided or done. Comments If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Conditions The 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
modifier		0..*	CodeableConcept	Element id ClaimResponse.addItem.detail.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Conditions The 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
quantity	C	0..1	https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity	Element id ClaimResponse.addItem.detail.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. 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. Data type https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity Conditions The 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
unitPrice		0..1	Money	Element id ClaimResponse.addItem.detail.unitPrice Short description Fee, charge or cost per item Definition If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Conditions The 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
factor		0..1	decimal	Element id ClaimResponse.addItem.detail.factor Short description Price scaling factor Definition A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	Element id ClaimResponse.addItem.detail.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Conditions The 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
noteNumber		0..*	positiveInt	Element id ClaimResponse.addItem.detail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.adjudication Short description Added items detail adjudication Definition The adjudication results.
subDetail		0..*	BackboneElement	Element id ClaimResponse.addItem.detail.subDetail Short description Insurer added line items Definition The third-tier service adjudications for payor added services. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
productOrService		1..1	CodeableConcept	Element id ClaimResponse.addItem.detail.subDetail.productOrService Short description Billing, service, product, or drug code Definition When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. Requirements Necessary to state what was provided or done. Comments If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. Data type CodeableConcept Binding Allowable service and product codes. USCLSCodes (example) Conditions The 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
modifier		0..*	CodeableConcept	Element id ClaimResponse.addItem.detail.subDetail.modifier Short description Service/Product billing modifiers Definition Item typification or modifiers codes to convey additional context for the product or service. Requirements To support inclusion of the item for adjudication or to charge an elevated fee. Comments For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. Data type CodeableConcept Binding Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example) Conditions The 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
quantity	C	0..1	https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity	Element id ClaimResponse.addItem.detail.subDetail.quantity Short description Count of products or services Definition The number of repetitions of a service or product. Requirements Required when the product or service code does not convey the quantity provided. 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. Data type https://fhir.kemkes.go.id/r4/StructureDefinition/SimpleQuantity Conditions The 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
unitPrice		0..1	Money	Element id ClaimResponse.addItem.detail.subDetail.unitPrice Short description Fee, charge or cost per item Definition If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. Requirements The amount charged to the patient by the provider for a single unit. Data type Money Conditions The 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
factor		0..1	decimal	Element id ClaimResponse.addItem.detail.subDetail.factor Short description Price scaling factor Definition A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount. Requirements When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. Comments To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). Data type decimal Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
net		0..1	Money	Element id ClaimResponse.addItem.detail.subDetail.net Short description Total item cost Definition The quantity times the unit price for an additional service or product or charge. Requirements Provides the total amount claimed for the group (if a grouper) or the line item. Comments For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. Data type Money Conditions The 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
noteNumber		0..*	positiveInt	Element id ClaimResponse.addItem.detail.subDetail.noteNumber Short description Applicable note numbers Definition The numbers associated with notes below which apply to the adjudication of this item. Requirements Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
adjudication		1..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.addItem.detail.subDetail.adjudication Short description Added items detail adjudication Definition The adjudication results.
adjudication		0..*	see (adjudication)	There are no (further) constraints on this element Element id ClaimResponse.adjudication Short description Header-level adjudication Definition The adjudication results which are presented at the header level rather than at the line-item or add-item levels. Requirements Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
total	Σ	0..*	BackboneElement	Element id ClaimResponse.total Short description Adjudication totals Definition Categorized monetary totals for the adjudication. Requirements To provide the requestor with financial totals by category for the adjudication. Comments Totals for amounts submitted, co-pays, benefits payable etc. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.total.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.total.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.total.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
category	Σ	1..1	CodeableConcept	Element id ClaimResponse.total.category Short description Type of adjudication information Definition A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. Requirements Needed to convey the type of total provided. Comments For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. Data type CodeableConcept Binding The adjudication codes. AdjudicationValueCodes (example) Conditions The 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
amount	Σ	1..1	Money	Element id ClaimResponse.total.amount Short description Financial total for the category Definition Monetary total amount associated with the category. Requirements Needed to convey the total monetary amount. Data type Money Conditions The 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
payment		0..1	BackboneElement	Element id ClaimResponse.payment Short description Payment Details Definition Payment details for the adjudication of the claim. Requirements Needed to convey references to the financial instrument that has been used if payment has been made. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.payment.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.payment.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.payment.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
type		1..1	CodeableConcept	Element id ClaimResponse.payment.type Short description Partial or complete payment Definition Whether this represents partial or complete payment of the benefits payable. Requirements To advise the requestor when the insurer believes all payments to have been completed. 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. Data type CodeableConcept Binding The type (partial, complete) of the payment. ExamplePaymentTypeCodes (example) Conditions The 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
adjustment		0..1	Money	Element id ClaimResponse.payment.adjustment Short description Payment adjustment for non-claim issues Definition Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. Requirements To advise the requestor of adjustments applied to the payment. Comments Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider. Data type Money Conditions The 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
adjustmentReason		0..1	CodeableConcept	Element id ClaimResponse.payment.adjustmentReason Short description Explanation for the adjustment Definition Reason for the payment adjustment. 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. Data type CodeableConcept Binding Payment Adjustment reason codes. PaymentAdjustmentReasonCodes (example) Conditions The 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
date		0..1	date	Element id ClaimResponse.payment.date Short description Expected date of payment Definition Estimated date the payment will be issued or the actual issue date of payment. Requirements To advise the payee when payment can be expected. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
amount		1..1	Money	Element id ClaimResponse.payment.amount Short description Payable amount after adjustment Definition Benefits payable less any payment adjustment. Requirements Needed to provide the actual payment amount. Data type Money Conditions The 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
identifier		0..1	Identifier	Element id ClaimResponse.payment.identifier Short description Business identifier for the payment Definition Issuer's unique identifier for the payment instrument. Requirements Enable the receiver to reconcile when payment received. Comments For example: EFT number or check number. Data type Identifier Conditions The 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
fundsReserve		0..1	CodeableConcept	Element id ClaimResponse.fundsReserve Short description Funds reserved status Definition A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. Requirements Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. Comments Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. Data type CodeableConcept Binding For whom funds are to be reserved: (Patient, Provider, None). Funds Reservation Codes (example) Conditions The 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
formCode		0..1	CodeableConcept	Element id ClaimResponse.formCode Short description Printed form identifier Definition A code for the form to be used for printing the content. Requirements Needed to specify the specific form used for producing output for this response. Comments May be needed to identify specific jurisdictional forms. Data type CodeableConcept Binding The forms codes. Form Codes (example) Conditions The 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
form	C	0..1	Attachment	Element id ClaimResponse.form Short description Printed reference or actual form Definition The actual form, by reference or inclusion, for printing the content or an EOB. Requirements Needed to include the specific form used for producing output for this response. Comments Needed to permit insurers to include the actual form. Data type Attachment Conditions The 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
processNote		0..*	BackboneElement	Element id ClaimResponse.processNote Short description Note concerning adjudication Definition A note that describes or explains adjudication results in a human readable form. Requirements Provides the insurer specific textual explanations associated with the processing. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.processNote.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.processNote.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.processNote.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
number		0..1	positiveInt	Element id ClaimResponse.processNote.number Short description Note instance identifier Definition A number to uniquely identify a note entry. Requirements Necessary to provide a mechanism to link from adjudications. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
type		0..1	codeBinding	Element id ClaimResponse.processNote.type Short description display \| print \| printoper Definition The business purpose of the note text. Requirements To convey the expectation for when the text is used. Data type code Binding The presentation types of notes. NoteType (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		1..1	string	Element id ClaimResponse.processNote.text Short description Note explanatory text Definition The explanation or description associated with the processing. Requirements Required to provide human readable explanation. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	CodeableConceptBinding	Element id ClaimResponse.processNote.language Short description Language of the text Definition A code to define the language used in the text of the note. Requirements Note text may vary from the resource defined language. Comments Only required if the language is different from the resource language. Data type CodeableConcept Binding A human language. CommonLanguages (preferred) Conditions The 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
communicationRequest	C	0..*	Reference(https://fhir.kemkes.go.id/r4/StructureDefinition/CommunicationRequest)	Element id ClaimResponse.communicationRequest Short description Request for additional information Definition Request for additional supporting or authorizing information. Requirements Need to communicate insurer request for additional information required to support the adjudication. Comments For example: professional reports, documents, images, clinical resources, or accident reports. Data type Reference(https://fhir.kemkes.go.id/r4/StructureDefinition/CommunicationRequest) Conditions The 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)
insurance		0..*	BackboneElement	Element id ClaimResponse.insurance Short description Patient insurance information Definition Financial instruments for reimbursement for the health care products and services specified on the claim. Requirements At least one insurer is required for a claim to be a claim. Comments All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.insurance.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.insurance.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.insurance.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
sequence		1..1	positiveInt	Element id ClaimResponse.insurance.sequence Short description Insurance instance identifier Definition A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. Requirements To maintain order of the coverages. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
focal		1..1	boolean	Element id ClaimResponse.insurance.focal Short description Coverage to be used for adjudication Definition A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. Requirements To identify which coverage in the list is being used to adjudicate this claim. Comments A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
coverage	C	1..1	Reference(Coverage)	Element id ClaimResponse.insurance.coverage Short description Insurance information Definition Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. Requirements Required to allow the adjudicator to locate the correct policy and history within their information system. 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. Data type Reference(Coverage) Conditions The 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)
businessArrangement		0..1	string	Element id ClaimResponse.insurance.businessArrangement Short description Additional provider contract number Definition A business agreement number established between the provider and the insurer for special business processing purposes. Requirements Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
claimResponse	C	0..1	Reference(ClaimResponse)	Element id ClaimResponse.insurance.claimResponse Short description Adjudication results Definition The result of the adjudication of the line items for the Coverage specified in this insurance. Requirements An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim. Comments Must not be specified when 'focal=true' for this insurance. Data type Reference(ClaimResponse) Conditions The 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)
error		0..*	BackboneElement	Element id ClaimResponse.error Short description Processing errors Definition Errors encountered during the processing of the adjudication. Requirements Need to communicate processing issues to the requestor. Comments If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present. Data type BackboneElement Conditions The 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
id		0..1	string	There are no (further) constraints on this element Element id ClaimResponse.error.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.error.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension 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
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id ClaimResponse.error.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
itemSequence		0..1	positiveInt	Element id ClaimResponse.error.itemSequence Short description Item sequence number Definition The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. Requirements Provides references to the claim items. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
detailSequence		0..1	positiveInt	Element id ClaimResponse.error.detailSequence Short description Detail sequence number Definition The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. Requirements Provides references to the claim details within the claim item. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subDetailSequence		0..1	positiveInt	Element id ClaimResponse.error.subDetailSequence Short description Subdetail sequence number Definition The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. Requirements Provides references to the claim sub-details within the claim detail. Data type positiveInt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
code		1..1	CodeableConcept	Element id ClaimResponse.error.code Short description Error code detailing processing issues Definition An error code, from a specified code system, which details why the claim could not be adjudicated. Requirements Required to convey processing errors. 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. Data type CodeableConcept Binding The adjudication error codes. Adjudication Error Codes (example) Conditions The 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

Examples

Dictionary

ClaimResponse
Short	Response to a claim predetermination or preauthorization
Definition	This resource provides the adjudication details from the processing of a Claim resource.
Cardinality	0..*
Alias	Remittance 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
Short	Logical id of this artifact
Definition	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Cardinality	0..1
Type	string
Summary	True
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
Short	Metadata about the resource
Definition	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Cardinality	0..1
Type	Meta
Summary	True
Constraints	ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
ClaimResponse.implicitRules
Short	A set of rules under which this content was created
Definition	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Cardinality	0..1
Type	uri
Modifier	True
Summary	True
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
Short	Language of the resource content
Definition	The base language in which the resource is written.
Cardinality	0..1
Type	code
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
Short	Text 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.
Cardinality	0..1
Type	Narrative
Alias	narrative, 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
Short	Contained, 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.
Cardinality	0..*
Type	Resource
Alias	inline 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
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Alias	extensions, 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
Short	Business Identifier for a claim response
Definition	A unique identifier assigned to this claim response.
Cardinality	0..*
Type	Identifier
Requirements	Allows claim responses to be distinguished and referenced.
Conditions	The 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
Short	active \| cancelled \| draft \| entered-in-error
Definition	The status of the resource instance.
Cardinality	1..1
Type	code
Binding	A code specifying the state of the resource instance. FinancialResourceStatusCodes (required)
Modifier	True
Summary	True
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
Short	More granular claim type
Definition	A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Cardinality	1..1
Type	CodeableConcept
Binding	The type or discipline-style of the claim. ClaimTypeCodes (extensible)
Summary	True
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.
Conditions	The 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
Short	More granular claim type
Definition	A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	claim \| 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.
Cardinality	1..1
Type	code
Binding	Claim, preauthorization, predetermination. Use (required)
Summary	True
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
Short	The recipient of the products and services
Definition	The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
Cardinality	1..1
Type	Reference(Patient)
Summary	True
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.
Conditions	The 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
Short	Response creation date
Definition	The date this resource was created.
Cardinality	1..1
Type	dateTime
Summary	True
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
Short	Party responsible for reimbursement
Definition	The party responsible for authorization, adjudication and reimbursement.
Cardinality	1..1
Type	Reference(Organization)
Summary	True
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.
Conditions	The 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
Short	Party responsible for the claim
Definition	The provider which is responsible for the claim, predetermination or preauthorization.
Cardinality	0..1
Type	Reference(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.
Conditions	The 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
Short	Id of resource triggering adjudication
Definition	Original request resource reference.
Cardinality	0..1
Type	Reference(Claim)
Summary	True
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.
Conditions	The 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
Short	queued \| complete \| error \| partial
Definition	The outcome of the claim, predetermination, or preauthorization processing.
Cardinality	1..1
Type	code
Binding	The result of the claim processing. ClaimProcessingCodes (required)
Summary	True
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
Short	Disposition Message
Definition	A human readable description of the status of the adjudication.
Cardinality	0..1
Type	string
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
Short	Preauthorization reference
Definition	Reference from the Insurer which is used in later communications which refers to this adjudication.
Cardinality	0..1
Type	string
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
Short	Preauthorization reference effective period
Definition	The time frame during which this authorization is effective.
Cardinality	0..1
Type	Period
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.
Conditions	The 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
Short	Party to be paid any benefits payable
Definition	Type of Party to be reimbursed: subscriber, provider, other.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Adjudication for claim line items
Definition	A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Cardinality	0..*
Type	BackboneElement
Requirements	The adjudication for items provided on the claim.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.item.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Claim item instance identifier
Definition	A number to uniquely reference the claim item entries.
Cardinality	1..1
Type	positiveInt
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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Adjudication details
Definition	If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Cardinality	1..*
Type	BackboneElement
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.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.item.adjudication.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Type of adjudication information
Definition	A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
Cardinality	1..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Explanation of adjudication outcome
Definition	A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Monetary amount
Definition	Monetary amount associated with the category.
Cardinality	0..1
Type	Money
Requirements	Most adjuciation categories convey a monetary amount.
Comments	For example: amount submitted, eligible amount, co-payment, and benefit payable.
Conditions	The 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
Short	Non-monetary value
Definition	A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Cardinality	0..1
Type	decimal
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
Short	Adjudication for claim details
Definition	A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Cardinality	0..*
Type	BackboneElement
Requirements	The adjudication for details provided on the claim.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.item.detail.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Claim detail instance identifier
Definition	A number to uniquely reference the claim detail entry.
Cardinality	1..1
Type	positiveInt
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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Detail level adjudication details
Definition	The adjudication results.
Cardinality	1..*
Type	see (adjudication)
ClaimResponse.item.detail.subDetail
Short	Adjudication for claim sub-details
Definition	A sub-detail adjudication of a simple product or service.
Cardinality	0..*
Type	BackboneElement
Requirements	The adjudication for sub-details provided on the claim.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.item.detail.subDetail.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Claim sub-detail instance identifier
Definition	A number to uniquely reference the claim sub-detail entry.
Cardinality	1..1
Type	positiveInt
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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Subdetail level adjudication details
Definition	The adjudication results.
Cardinality	0..*
Type	see (adjudication)
ClaimResponse.addItem
Short	Insurer added line items
Definition	The first-tier service adjudications for payor added product or service lines.
Cardinality	0..*
Type	BackboneElement
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.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.addItem.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Item sequence number
Definition	Claim items which this service line is intended to replace.
Cardinality	0..*
Type	positiveInt
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
Short	Detail sequence number
Definition	The sequence number of the details within the claim item which this line is intended to replace.
Cardinality	0..*
Type	positiveInt
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
Short	Subdetail sequence number
Definition	The sequence number of the sub-details within the details within the claim item which this line is intended to replace.
Cardinality	0..*
Type	positiveInt
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
Short	Authorized providers
Definition	The providers who are authorized for the services rendered to the patient.
Cardinality	0..*
Type	Reference(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.
Conditions	The 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
Short	Billing, service, product, or drug code
Definition	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality	1..1
Type	CodeableConcept
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'.
Conditions	The 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
Short	Service/Product billing modifiers
Definition	Item typification or modifiers codes to convey additional context for the product or service.
Cardinality	0..*
Type	CodeableConcept
Binding	Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example)
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.
Conditions	The 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
Short	Program the product or service is provided under
Definition	Identifies the program under which this may be recovered.
Cardinality	0..*
Type	CodeableConcept
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.
Conditions	The 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]
Short	Date or dates of service or product delivery
Definition	The date or dates when the service or product was supplied, performed or completed.
Cardinality	0..1
Type	date, Period
Requirements	Needed to determine whether the service or product was provided during the term of the insurance coverage.
Conditions	The 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]
Short	Place of service or where product was supplied
Definition	Where the product or service was provided.
Cardinality	0..1
Type	CodeableConcept, 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.
Conditions	The 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
Short	Count of products or services
Definition	The number of repetitions of a service or product.
Cardinality	0..1
Type	https://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.
Conditions	The 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
Short	Fee, charge or cost per item
Definition	If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Cardinality	0..1
Type	Money
Requirements	The amount charged to the patient by the provider for a single unit.
Conditions	The 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
Short	Price scaling factor
Definition	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Cardinality	0..1
Type	decimal
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
Short	Total item cost
Definition	The quantity times the unit price for an additional service or product or charge.
Cardinality	0..1
Type	Money
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.
Conditions	The 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
Short	Anatomical location
Definition	Physical service site on the patient (limb, tooth, etc.).
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Anatomical sub-location
Definition	A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Cardinality	0..*
Type	CodeableConcept
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.
Conditions	The 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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Added items adjudication
Definition	The adjudication results.
Cardinality	1..*
Type	see (adjudication)
ClaimResponse.addItem.detail
Short	Insurer added line details
Definition	The second-tier service adjudications for payor added services.
Cardinality	0..*
Type	BackboneElement
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.addItem.detail.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Billing, service, product, or drug code
Definition	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality	1..1
Type	CodeableConcept
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'.
Conditions	The 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
Short	Service/Product billing modifiers
Definition	Item typification or modifiers codes to convey additional context for the product or service.
Cardinality	0..*
Type	CodeableConcept
Binding	Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example)
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.
Conditions	The 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
Short	Count of products or services
Definition	The number of repetitions of a service or product.
Cardinality	0..1
Type	https://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.
Conditions	The 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
Short	Fee, charge or cost per item
Definition	If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Cardinality	0..1
Type	Money
Requirements	The amount charged to the patient by the provider for a single unit.
Conditions	The 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
Short	Price scaling factor
Definition	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Cardinality	0..1
Type	decimal
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
Short	Total item cost
Definition	The quantity times the unit price for an additional service or product or charge.
Cardinality	0..1
Type	Money
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.
Conditions	The 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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Added items detail adjudication
Definition	The adjudication results.
Cardinality	1..*
Type	see (adjudication)
ClaimResponse.addItem.detail.subDetail
Short	Insurer added line items
Definition	The third-tier service adjudications for payor added services.
Cardinality	0..*
Type	BackboneElement
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.addItem.detail.subDetail.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Billing, service, product, or drug code
Definition	When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Cardinality	1..1
Type	CodeableConcept
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'.
Conditions	The 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
Short	Service/Product billing modifiers
Definition	Item typification or modifiers codes to convey additional context for the product or service.
Cardinality	0..*
Type	CodeableConcept
Binding	Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ModifierTypeCodes (example)
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.
Conditions	The 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
Short	Count of products or services
Definition	The number of repetitions of a service or product.
Cardinality	0..1
Type	https://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.
Conditions	The 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
Short	Fee, charge or cost per item
Definition	If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Cardinality	0..1
Type	Money
Requirements	The amount charged to the patient by the provider for a single unit.
Conditions	The 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
Short	Price scaling factor
Definition	A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Cardinality	0..1
Type	decimal
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
Short	Total item cost
Definition	The quantity times the unit price for an additional service or product or charge.
Cardinality	0..1
Type	Money
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.
Conditions	The 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
Short	Applicable note numbers
Definition	The numbers associated with notes below which apply to the adjudication of this item.
Cardinality	0..*
Type	positiveInt
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
Short	Added items detail adjudication
Definition	The adjudication results.
Cardinality	1..*
Type	see (adjudication)
ClaimResponse.adjudication
Short	Header-level adjudication
Definition	The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Cardinality	0..*
Type	see (adjudication)
Requirements	Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
ClaimResponse.total
Short	Adjudication totals
Definition	Categorized monetary totals for the adjudication.
Cardinality	0..*
Type	BackboneElement
Summary	True
Requirements	To provide the requestor with financial totals by category for the adjudication.
Comments	Totals for amounts submitted, co-pays, benefits payable etc.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.total.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Type of adjudication information
Definition	A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Cardinality	1..1
Type	CodeableConcept
Binding	The adjudication codes. AdjudicationValueCodes (example)
Summary	True
Requirements	Needed to convey the type of total provided.
Comments	For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Conditions	The 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
Short	Financial total for the category
Definition	Monetary total amount associated with the category.
Cardinality	1..1
Type	Money
Summary	True
Requirements	Needed to convey the total monetary amount.
Conditions	The 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
Short	Payment Details
Definition	Payment details for the adjudication of the claim.
Cardinality	0..1
Type	BackboneElement
Requirements	Needed to convey references to the financial instrument that has been used if payment has been made.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.payment.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Partial or complete payment
Definition	Whether this represents partial or complete payment of the benefits payable.
Cardinality	1..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Payment adjustment for non-claim issues
Definition	Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Cardinality	0..1
Type	Money
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.
Conditions	The 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
Short	Explanation for the adjustment
Definition	Reason for the payment adjustment.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Expected date of payment
Definition	Estimated date the payment will be issued or the actual issue date of payment.
Cardinality	0..1
Type	date
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
Short	Payable amount after adjustment
Definition	Benefits payable less any payment adjustment.
Cardinality	1..1
Type	Money
Requirements	Needed to provide the actual payment amount.
Conditions	The 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
Short	Business identifier for the payment
Definition	Issuer's unique identifier for the payment instrument.
Cardinality	0..1
Type	Identifier
Requirements	Enable the receiver to reconcile when payment received.
Comments	For example: EFT number or check number.
Conditions	The 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
Short	Funds reserved status
Definition	A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Printed form identifier
Definition	A code for the form to be used for printing the content.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Printed reference or actual form
Definition	The actual form, by reference or inclusion, for printing the content or an EOB.
Cardinality	0..1
Type	Attachment
Requirements	Needed to include the specific form used for producing output for this response.
Comments	Needed to permit insurers to include the actual form.
Conditions	The 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
Short	Note concerning adjudication
Definition	A note that describes or explains adjudication results in a human readable form.
Cardinality	0..*
Type	BackboneElement
Requirements	Provides the insurer specific textual explanations associated with the processing.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.processNote.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Note instance identifier
Definition	A number to uniquely identify a note entry.
Cardinality	0..1
Type	positiveInt
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
Short	display \| print \| printoper
Definition	The business purpose of the note text.
Cardinality	0..1
Type	code
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
Short	Note explanatory text
Definition	The explanation or description associated with the processing.
Cardinality	1..1
Type	string
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
Short	Language of the text
Definition	A code to define the language used in the text of the note.
Cardinality	0..1
Type	CodeableConcept
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.
Conditions	The 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
Short	Request for additional information
Definition	Request for additional supporting or authorizing information.
Cardinality	0..*
Type	Reference(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.
Conditions	The 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
Short	Patient insurance information
Definition	Financial instruments for reimbursement for the health care products and services specified on the claim.
Cardinality	0..*
Type	BackboneElement
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.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.insurance.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Insurance instance identifier
Definition	A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Cardinality	1..1
Type	positiveInt
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
Short	Coverage to be used for adjudication
Definition	A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Cardinality	1..1
Type	boolean
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
Short	Insurance information
Definition	Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Cardinality	1..1
Type	Reference(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.
Conditions	The 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
Short	Additional provider contract number
Definition	A business agreement number established between the provider and the insurer for special business processing purposes.
Cardinality	0..1
Type	string
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
Short	Adjudication results
Definition	The result of the adjudication of the line items for the Coverage specified in this insurance.
Cardinality	0..1
Type	Reference(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.
Conditions	The 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
Short	Processing errors
Definition	Errors encountered during the processing of the adjudication.
Cardinality	0..*
Type	BackboneElement
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.
Conditions	The 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
Short	Unique id for inter-element referencing
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Cardinality	0..1
Type	string
Mappings	rim: n/a
ClaimResponse.error.extension
Short	Additional 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.
Cardinality	0..*
Type	Extension
Alias	extensions, 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
Short	Extensions 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).
Cardinality	0..*
Type	Extension
Modifier	True
Summary	True
Alias	extensions, 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
Short	Item sequence number
Definition	The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Cardinality	0..1
Type	positiveInt
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
Short	Detail sequence number
Definition	The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Cardinality	0..1
Type	positiveInt
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
Short	Subdetail sequence number
Definition	The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Cardinality	0..1
Type	positiveInt
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
Short	Error code detailing processing issues
Definition	An error code, from a specified code system, which details why the claim could not be adjudicated.
Cardinality	1..1
Type	CodeableConcept
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.
Conditions	The 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