MII_PR_MTB_Antwort_Kostenuebernahme (ClaimResponse) | C | | ClaimResponse | There are no (further) constraints on this element Element idClaimResponse Short descriptionResponse to a claim predetermination or preauthorization Alternate namesRemittance Advice DefinitionThis resource provides the adjudication details from the processing of a Claim resource.
Data typeClaimResponse 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
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.id Short descriptionLogical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
CommentsThe only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Data typestring |
meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element idClaimResponse.meta Short descriptionMetadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Data typeMeta Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.meta.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.meta.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension SlicingUnordered, 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 |
versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idClaimResponse.meta.versionId Short descriptionVersion specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
CommentsThe server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
Data typeid Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element idClaimResponse.meta.lastUpdated Short descriptionWhen the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed.
CommentsThis value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Data typeinstant Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idClaimResponse.meta.source Short descriptionIdentifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
CommentsIn the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.
This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Data typeuri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idClaimResponse.meta.profile Short descriptionProfiles this resource claims to conform to DefinitionCommentsIt is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Data typecanonical(StructureDefinition) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idClaimResponse.meta.security Short descriptionSecurity Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
CommentsThe security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Data typeCoding BindingSecurity Labels from the Healthcare Privacy and Security Classification System.
All Security Labels (extensible) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idClaimResponse.meta.tag Short descriptionTags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
CommentsThe tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Data typeCoding BindingCodes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
CommonTags (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idClaimResponse.implicitRules Short descriptionA set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
CommentsAsserting 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 typeuri Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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language | | 0..1 | codeBinding | There are no (further) constraints on this element Element idClaimResponse.language Short descriptionLanguage of the resource content DefinitionThe base language in which the resource is written.
CommentsLanguage 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 typecode BindingCommonLanguages (preferred) Binding extensionsConstraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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text | | 0..1 | Narrative | There are no (further) constraints on this element Element idClaimResponse.text Short descriptionText summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
CommentsContained 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 typeNarrative Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
contained | | 0..* | Resource | There are no (further) constraints on this element Element idClaimResponse.contained Short descriptionContained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
CommentsThis 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 typeResource Mappings |
extension | S C | 0..* | Extension | Element idClaimResponse.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension SlicingUnordered, Open, by url(Value) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
Entscheidung | S C | 0..1 | Extension(CodeableConcept) | Element idClaimResponse.extension:Entscheidung Short descriptionEntscheidung Alternate namesextensions, user content DefinitionStadium der Antwort auf den Antrag zur Kostenuebernahme
CommentsThere 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 typeExtension(CodeableConcept) Extension URLhttps://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-entscheidung ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
Ablehnungsgrund | C | 0..1 | Extension(CodeableConcept) | Element idClaimResponse.extension:Ablehnungsgrund Short descriptionAblehnungsgrund Alternate namesextensions, user content DefinitionStadium der Antwort auf den Antrag zur Kostenuebernahme
CommentsThere 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 typeExtension(CodeableConcept) Extension URLhttps://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-ex-mtb-antwort-kostenuebernahme-ablehnungsgrund ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists() Mappings |
modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.modifierExtension Short descriptionExtensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
identifier | | 0..* | Identifier | There are no (further) constraints on this element Element idClaimResponse.identifier Short descriptionBusiness Identifier for a claim response DefinitionA unique identifier assigned to this claim response.
RequirementsAllows claim responses to be distinguished and referenced.
Data typeIdentifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- workflow: Event.identifier
- w5: FiveWs.identifier
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status | S Σ ?! | 1..1 | codeBindingPattern | Element idClaimResponse.status Short descriptionStatus der FHIR-Ressource DefinitionStatus der FHIR-Ressource, statisch auf #active gesetzt, da retrospektive Datenerschließung
RequirementsNeed 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'.
CommentsThis element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Data typecode BindingA 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()) Patternactive Mappings- workflow: Event.status
- w5: FiveWs.status
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type | S Σ | 1..1 | CodeableConceptBinding | Element idClaimResponse.type Short descriptionKategorie des Antragstellers DefinitionKategorie des Antragstellers - z.B. stationär, ambulant, Apotheke
RequirementsSome jurisdictions need a finer grained claim type for routing and adjudication.
CommentsThis may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Data typeCodeableConcept BindingThe type or discipline-style of the claim.
MII_VS_MTB_Antrag_Kostenuebernahme_Type (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
subType | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.subType Short descriptionMore granular claim type DefinitionA finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
RequirementsSome jurisdictions need a finer grained claim type for routing and adjudication.
CommentsThis may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Data typeCodeableConcept BindingA more granular claim typecode.
ExampleClaimSubTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
use | S Σ | 1..1 | codeBinding | Element idClaimResponse.use Short descriptionArt des Kostenerstattungsantrags (claim, predetermination, preauthorization) Definitionfolgt den Definitionen wie im amerikanischen Gesundsheitswesen gebräuchlich. claim: Erstattungsantrag nach erfolgter Therapie; predetermination: unverbindliche Anfrage, insb. zu Anteilen der Kostenübernahme; preauthorization: Anfrage nach möglicher Erstattung für zukünftige Therapie
RequirementsThis element is required to understand the nature of the request for adjudication.
Data typecode BindingClaim, preauthorization, predetermination.
Use (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
patient | S Σ | 1..1 | Reference(Patient) | There are no (further) constraints on this element Element idClaimResponse.patient Short descriptionThe recipient of the products and services DefinitionThe party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
RequirementsThe patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Data typeReference(Patient) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- w5: FiveWs.subject[x]
- w5: FiveWs.subject
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created | S Σ | 1..1 | dateTime | Element idClaimResponse.created Short descriptionDatum der Zusage / des Widerspruchs DefinitionThe date this resource was created.
RequirementsNeed to record a timestamp for use by both the recipient and the issuer.
Data typedateTime 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
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insurer | S Σ | 1..1 | Reference(Organization) | There are no (further) constraints on this element Element idClaimResponse.insurer Short descriptionParty responsible for reimbursement DefinitionThe party responsible for authorization, adjudication and reimbursement.
RequirementsTo be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Data typeReference(Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- workflow: Event.performer
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requestor | | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idClaimResponse.requestor Short descriptionParty responsible for the claim DefinitionThe provider which is responsible for the claim, predetermination or preauthorization.
CommentsTypically 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 typeReference(Practitioner | PractitionerRole | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
request | S Σ | 0..1 | Reference(MII_PR_MTB_Antrag_Kostenuebernahme) | Element idClaimResponse.request Short descriptionAntrag DefinitionDazugehöriger Antrag zur Kostenübernahme
Data typeReference(MII_PR_MTB_Antrag_Kostenuebernahme) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- workflow: Event.basedOn
- w5: FiveWs.why[x]
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outcome | S Σ | 1..1 | codeBindingPattern | Element idClaimResponse.outcome Short descriptionErgebnis der Kostenübernahme DefinitionErgebnis der Kostenübernahme. Für den Fall der Sekundärdatenenutzung ist davon auszugehen, dass die Kostenerstattung bereits erfolgt ist. Daher ist der Status auf #complete gesetzt.
RequirementsTo advise the requestor of an overall processing outcome.
CommentsThe 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 typecode BindingThe 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()) Patterncomplete |
disposition | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.disposition Short descriptionDisposition Message DefinitionA human readable description of the status of the adjudication.
RequirementsProvided for user display.
Data typestring Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
preAuthRef | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.preAuthRef Short descriptionPreauthorization reference DefinitionReference from the Insurer which is used in later communications which refers to this adjudication.
RequirementsOn subsequent claims, the insurer may require the provider to quote this value.
CommentsThis value is only present on preauthorization adjudications.
Data typestring Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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preAuthPeriod | | 0..1 | Period | There are no (further) constraints on this element Element idClaimResponse.preAuthPeriod Short descriptionPreauthorization reference effective period DefinitionThe time frame during which this authorization is effective.
RequirementsTo convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
Data typePeriod Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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payeeType | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payeeType Short descriptionParty to be paid any benefits payable DefinitionType of Party to be reimbursed: subscriber, provider, other.
RequirementsNeed to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Data typeCodeableConcept BindingA code for the party to be reimbursed.
Claim Payee Type Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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item | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item Short descriptionAdjudication for claim line items DefinitionA claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
RequirementsThe adjudication for items provided on the claim.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
itemSequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.itemSequence Short descriptionClaim item instance identifier DefinitionA number to uniquely reference the claim item entries.
RequirementsNecessary to provide a mechanism to link the adjudication result to the submitted claim item.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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adjudication | | 1..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.adjudication Short descriptionAdjudication details DefinitionIf this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
RequirementsThe adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
category | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.category Short descriptionType of adjudication information DefinitionA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
RequirementsNeeded to enable understanding of the context of the other information in the adjudication.
CommentsFor example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Data typeCodeableConcept BindingAdjudicationValueCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
reason | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.reason Short descriptionExplanation of adjudication outcome DefinitionA code supporting the understanding of the adjudication result and explaining variance from expected amount.
RequirementsTo support understanding of variance from adjudication expectations.
CommentsFor example may indicate that the funds for this benefit type have been exhausted.
Data typeCodeableConcept BindingThe adjudication reason codes.
AdjudicationReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
amount | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.amount Short descriptionMonetary amount DefinitionMonetary amount associated with the category.
RequirementsMost adjuciation categories convey a monetary amount.
CommentsFor example: amount submitted, eligible amount, co-payment, and benefit payable.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
value | | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.item.adjudication.value Short descriptionNon-monetary value DefinitionA non-monetary value associated with the category. Mutually exclusive to the amount element above.
RequirementsSome adjudication categories convey a percentage or a fixed value.
CommentsFor example: eligible percentage or co-payment percentage.
Data typedecimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
detail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.detail Short descriptionAdjudication for claim details DefinitionA claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
RequirementsThe adjudication for details provided on the claim.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.detail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
detailSequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.detailSequence Short descriptionClaim detail instance identifier DefinitionA number to uniquely reference the claim detail entry.
RequirementsNecessary to provide a mechanism to link the adjudication result to the submitted claim detail.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt 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 idClaimResponse.item.detail.adjudication Short descriptionDetail level adjudication details DefinitionThe adjudication results.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
subDetail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail Short descriptionAdjudication for claim sub-details DefinitionA sub-detail adjudication of a simple product or service.
RequirementsThe adjudication for sub-details provided on the claim.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
subDetailSequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.subDetailSequence Short descriptionClaim sub-detail instance identifier DefinitionA number to uniquely reference the claim sub-detail entry.
RequirementsNecessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.item.detail.subDetail.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt 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 idClaimResponse.item.detail.subDetail.adjudication Short descriptionSubdetail level adjudication details DefinitionThe adjudication results.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
addItem | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem Short descriptionInsurer added line items DefinitionThe first-tier service adjudications for payor added product or service lines.
RequirementsInsurers 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 typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
itemSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.itemSequence Short descriptionItem sequence number DefinitionClaim items which this service line is intended to replace.
RequirementsProvides references to the claim items.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
detailSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detailSequence Short descriptionDetail sequence number DefinitionThe sequence number of the details within the claim item which this line is intended to replace.
RequirementsProvides references to the claim details within the claim item.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
subdetailSequence | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.subdetailSequence Short descriptionSubdetail sequence number DefinitionThe sequence number of the sub-details within the details within the claim item which this line is intended to replace.
RequirementsProvides references to the claim sub-details within the claim detail.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
provider | | 0..* | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idClaimResponse.addItem.provider Short descriptionAuthorized providers DefinitionThe providers who are authorized for the services rendered to the patient.
RequirementsInsurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Data typeReference(Practitioner | PractitionerRole | Organization) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.productOrService Short descriptionBilling, service, product, or drug code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
RequirementsNecessary to state what was provided or done.
CommentsIf 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 typeCodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.modifier Short descriptionService/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
RequirementsTo support inclusion of the item for adjudication or to charge an elevated fee.
CommentsFor 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 typeCodeableConcept BindingItem type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
ModifierTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
programCode | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.programCode Short descriptionProgram the product or service is provided under DefinitionIdentifies the program under which this may be recovered.
RequirementsCommonly used in in the identification of publicly provided program focused on population segments or disease classifications.
CommentsFor example: Neonatal program, child dental program or drug users recovery program.
Data typeCodeableConcept BindingProgram specific reason codes.
ExampleProgramReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
serviced[x] | | 0..1 | | There are no (further) constraints on this element Element idClaimResponse.addItem.serviced[x] Short descriptionDate or dates of service or product delivery DefinitionThe date or dates when the service or product was supplied, performed or completed.
RequirementsNeeded to determine whether the service or product was provided during the term of the insurance coverage.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- w5: FiveWs.done[x]
- rim: 24.A
|
servicedDate | | | date | There are no (further) constraints on this element Data typedate |
servicedPeriod | | | Period | There are no (further) constraints on this element Data typePeriod |
location[x] | | 0..1 | | There are no (further) constraints on this element Element idClaimResponse.addItem.location[x] Short descriptionPlace of service or where product was supplied DefinitionWhere the product or service was provided.
RequirementsThe location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
BindingPlace of service: pharmacy, school, prison, etc.
ExampleServicePlaceCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings- w5: FiveWs.where[x]
- rim: 24.B
|
locationCodeableConcept | | | CodeableConcept | There are no (further) constraints on this element Data typeCodeableConcept |
locationAddress | | | Address | There are no (further) constraints on this element Data typeAddress |
locationReference | | | Reference(Location) | There are no (further) constraints on this element Data typeReference(Location) |
quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
RequirementsRequired when the product or service code does not convey the quantity provided.
Data typeSimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.unitPrice Short descriptionFee, charge or cost per item DefinitionIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
RequirementsThe amount charged to the patient by the provider for a single unit.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.factor Short descriptionPrice scaling factor DefinitionA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
RequirementsWhen discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
CommentsTo show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Data typedecimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
net | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
RequirementsProvides the total amount claimed for the group (if a grouper) or the line item.
CommentsFor example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
bodySite | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.bodySite Short descriptionAnatomical location DefinitionPhysical service site on the patient (limb, tooth, etc.).
RequirementsAllows insurer to validate specific procedures.
CommentsFor example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Data typeCodeableConcept BindingThe code for the teeth, quadrant, sextant and arch.
OralSiteCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
subSite | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.subSite Short descriptionAnatomical sub-location DefinitionA region or surface of the bodySite, e.g. limb region or tooth surface(s).
RequirementsAllows insurer to validate specific procedures.
Data typeCodeableConcept BindingThe code for the tooth surface and surface combinations.
SurfaceCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt 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 idClaimResponse.addItem.adjudication Short descriptionAdded items adjudication DefinitionThe adjudication results.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
detail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem.detail Short descriptionInsurer added line details DefinitionThe second-tier service adjudications for payor added services.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.productOrService Short descriptionBilling, service, product, or drug code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
RequirementsNecessary to state what was provided or done.
CommentsIf 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 typeCodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.modifier Short descriptionService/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
RequirementsTo support inclusion of the item for adjudication or to charge an elevated fee.
CommentsFor 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 typeCodeableConcept BindingItem type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
ModifierTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
RequirementsRequired when the product or service code does not convey the quantity provided.
Data typeSimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.unitPrice Short descriptionFee, charge or cost per item DefinitionIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
RequirementsThe amount charged to the patient by the provider for a single unit.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.factor Short descriptionPrice scaling factor DefinitionA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
RequirementsWhen discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
CommentsTo show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Data typedecimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
net | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
RequirementsProvides the total amount claimed for the group (if a grouper) or the line item.
CommentsFor example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt 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 idClaimResponse.addItem.detail.adjudication Short descriptionAdded items detail adjudication DefinitionThe adjudication results.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
subDetail | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail Short descriptionInsurer added line items DefinitionThe third-tier service adjudications for payor added services.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
productOrService | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.productOrService Short descriptionBilling, service, product, or drug code DefinitionWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
RequirementsNecessary to state what was provided or done.
CommentsIf 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 typeCodeableConcept BindingAllowable service and product codes.
USCLSCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
modifier | | 0..* | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.modifier Short descriptionService/Product billing modifiers DefinitionItem typification or modifiers codes to convey additional context for the product or service.
RequirementsTo support inclusion of the item for adjudication or to charge an elevated fee.
CommentsFor 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 typeCodeableConcept BindingItem type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
ModifierTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
quantity | | 0..1 | SimpleQuantity | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.quantity Short descriptionCount of products or services DefinitionThe number of repetitions of a service or product.
RequirementsRequired when the product or service code does not convey the quantity provided.
Data typeSimpleQuantity Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
unitPrice | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.unitPrice Short descriptionFee, charge or cost per item DefinitionIf the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
RequirementsThe amount charged to the patient by the provider for a single unit.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
factor | | 0..1 | decimal | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.factor Short descriptionPrice scaling factor DefinitionA real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
RequirementsWhen discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
CommentsTo show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Data typedecimal Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
net | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.net Short descriptionTotal item cost DefinitionThe quantity times the unit price for an additional service or product or charge.
RequirementsProvides the total amount claimed for the group (if a grouper) or the line item.
CommentsFor example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
noteNumber | | 0..* | positiveInt | There are no (further) constraints on this element Element idClaimResponse.addItem.detail.subDetail.noteNumber Short descriptionApplicable note numbers DefinitionThe numbers associated with notes below which apply to the adjudication of this item.
RequirementsProvides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Data typepositiveInt 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 idClaimResponse.addItem.detail.subDetail.adjudication Short descriptionAdded items detail adjudication DefinitionThe adjudication results.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
adjudication | | 0..* | see (adjudication) | There are no (further) constraints on this element Element idClaimResponse.adjudication Short descriptionHeader-level adjudication DefinitionThe adjudication results which are presented at the header level rather than at the line-item or add-item levels.
RequirementsSome insurers will receive line-items but provide the adjudication only at a summary or header-level.
Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
total | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.total Short descriptionAdjudication totals DefinitionCategorized monetary totals for the adjudication.
RequirementsTo provide the requestor with financial totals by category for the adjudication.
CommentsTotals for amounts submitted, co-pays, benefits payable etc.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.total.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.total.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.total.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
category | Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.total.category Short descriptionType of adjudication information DefinitionA code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
RequirementsNeeded to convey the type of total provided.
CommentsFor example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Data typeCodeableConcept BindingAdjudicationValueCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
amount | Σ | 1..1 | Money | There are no (further) constraints on this element Element idClaimResponse.total.amount Short descriptionFinancial total for the category DefinitionMonetary total amount associated with the category.
RequirementsNeeded to convey the total monetary amount.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
payment | | 0..1 | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.payment Short descriptionPayment Details DefinitionPayment details for the adjudication of the claim.
RequirementsNeeded to convey references to the financial instrument that has been used if payment has been made.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.payment.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.payment.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.payment.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
type | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payment.type Short descriptionPartial or complete payment DefinitionWhether this represents partial or complete payment of the benefits payable.
RequirementsTo advise the requestor when the insurer believes all payments to have been completed.
Data typeCodeableConcept BindingThe type (partial, complete) of the payment.
ExamplePaymentTypeCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
adjustment | | 0..1 | Money | There are no (further) constraints on this element Element idClaimResponse.payment.adjustment Short descriptionPayment adjustment for non-claim issues DefinitionTotal amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
RequirementsTo advise the requestor of adjustments applied to the payment.
CommentsInsurers 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 typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
adjustmentReason | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.payment.adjustmentReason Short descriptionExplanation for the adjustment DefinitionReason for the payment adjustment.
RequirementsNeeded to clarify the monetary adjustment.
Data typeCodeableConcept BindingPayment Adjustment reason codes.
PaymentAdjustmentReasonCodes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
date | | 0..1 | date | There are no (further) constraints on this element Element idClaimResponse.payment.date Short descriptionExpected date of payment DefinitionEstimated date the payment will be issued or the actual issue date of payment.
RequirementsTo advise the payee when payment can be expected.
Data typedate Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
amount | | 1..1 | Money | There are no (further) constraints on this element Element idClaimResponse.payment.amount Short descriptionPayable amount after adjustment DefinitionBenefits payable less any payment adjustment.
RequirementsNeeded to provide the actual payment amount.
Data typeMoney Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
identifier | | 0..1 | Identifier | There are no (further) constraints on this element Element idClaimResponse.payment.identifier Short descriptionBusiness identifier for the payment DefinitionIssuer's unique identifier for the payment instrument.
RequirementsEnable the receiver to reconcile when payment received.
CommentsFor example: EFT number or check number.
Data typeIdentifier Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
fundsReserve | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.fundsReserve Short descriptionFunds reserved status DefinitionA code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
RequirementsNeeded to advise the submitting provider on whether the rquest for reservation of funds has been honored.
CommentsFund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Data typeCodeableConcept BindingFor whom funds are to be reserved: (Patient, Provider, None).
Funds Reservation Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
formCode | | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.formCode Short descriptionPrinted form identifier DefinitionA code for the form to be used for printing the content.
RequirementsNeeded to specify the specific form used for producing output for this response.
CommentsMay be needed to identify specific jurisdictional forms.
Data typeCodeableConcept BindingForm Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
form | | 0..1 | Attachment | There are no (further) constraints on this element Element idClaimResponse.form Short descriptionPrinted reference or actual form DefinitionThe actual form, by reference or inclusion, for printing the content or an EOB.
RequirementsNeeded to include the specific form used for producing output for this response.
CommentsNeeded to permit insurers to include the actual form.
Data typeAttachment Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
processNote | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.processNote Short descriptionNote concerning adjudication DefinitionA note that describes or explains adjudication results in a human readable form.
RequirementsProvides the insurer specific textual explanations associated with the processing.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.processNote.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.processNote.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.processNote.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
number | | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.processNote.number Short descriptionNote instance identifier DefinitionA number to uniquely identify a note entry.
RequirementsNecessary to provide a mechanism to link from adjudications.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
type | | 0..1 | codeBinding | There are no (further) constraints on this element Element idClaimResponse.processNote.type Short descriptiondisplay | print | printoper DefinitionThe business purpose of the note text.
RequirementsTo convey the expectation for when the text is used.
Data typecode BindingThe presentation types of notes.
NoteType (required) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
text | | 1..1 | string | There are no (further) constraints on this element Element idClaimResponse.processNote.text Short descriptionNote explanatory text DefinitionThe explanation or description associated with the processing.
RequirementsRequired to provide human readable explanation.
Data typestring Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
language | | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idClaimResponse.processNote.language Short descriptionLanguage of the text DefinitionA code to define the language used in the text of the note.
RequirementsNote text may vary from the resource defined language.
CommentsOnly required if the language is different from the resource language.
Data typeCodeableConcept BindingCommonLanguages (preferred) Binding extensionsConstraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
communicationRequest | | 0..* | Reference(CommunicationRequest) | There are no (further) constraints on this element Element idClaimResponse.communicationRequest Short descriptionRequest for additional information DefinitionRequest for additional supporting or authorizing information.
RequirementsNeed to communicate insurer request for additional information required to support the adjudication.
CommentsFor example: professional reports, documents, images, clinical resources, or accident reports.
Data typeReference(CommunicationRequest) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
insurance | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.insurance Short descriptionPatient insurance information DefinitionFinancial instruments for reimbursement for the health care products and services specified on the claim.
RequirementsAt least one insurer is required for a claim to be a claim.
CommentsAll 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 typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) Mappings |
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.insurance.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.insurance.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.insurance.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
sequence | | 1..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.insurance.sequence Short descriptionInsurance instance identifier DefinitionA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
RequirementsTo maintain order of the coverages.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
focal | | 1..1 | boolean | There are no (further) constraints on this element Element idClaimResponse.insurance.focal Short descriptionCoverage to be used for adjudication DefinitionA flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
RequirementsTo identify which coverage in the list is being used to adjudicate this claim.
CommentsA 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 typeboolean Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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coverage | | 1..1 | Reference(Coverage) | There are no (further) constraints on this element Element idClaimResponse.insurance.coverage Short descriptionInsurance information DefinitionReference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
RequirementsRequired to allow the adjudicator to locate the correct policy and history within their information system.
Data typeReference(Coverage) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
businessArrangement | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.insurance.businessArrangement Short descriptionAdditional provider contract number DefinitionA business agreement number established between the provider and the insurer for special business processing purposes.
RequirementsProviders may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
Data typestring Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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claimResponse | | 0..1 | Reference(ClaimResponse) | There are no (further) constraints on this element Element idClaimResponse.insurance.claimResponse Short descriptionAdjudication results DefinitionThe result of the adjudication of the line items for the Coverage specified in this insurance.
RequirementsAn insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
CommentsMust not be specified when 'focal=true' for this insurance.
Data typeReference(ClaimResponse) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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error | | 0..* | BackboneElement | There are no (further) constraints on this element Element idClaimResponse.error Short descriptionProcessing errors DefinitionErrors encountered during the processing of the adjudication.
RequirementsNeed to communicate processing issues to the requestor.
CommentsIf the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Data typeBackboneElement Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
id | | 0..1 | string | There are no (further) constraints on this element Element idClaimResponse.error.id Short descriptionUnique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Data typestring Mappings |
extension | C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.error.extension Short descriptionAdditional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
CommentsThere 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 typeExtension 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 |
modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idClaimResponse.error.modifierExtension Short descriptionExtensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.
Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
RequirementsModifier 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.
CommentsThere 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 typeExtension 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 |
itemSequence | | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.itemSequence Short descriptionItem sequence number DefinitionThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
RequirementsProvides references to the claim items.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
detailSequence | | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.detailSequence Short descriptionDetail sequence number DefinitionThe sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
RequirementsProvides references to the claim details within the claim item.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
subDetailSequence | | 0..1 | positiveInt | There are no (further) constraints on this element Element idClaimResponse.error.subDetailSequence Short descriptionSubdetail sequence number DefinitionThe sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
RequirementsProvides references to the claim sub-details within the claim detail.
Data typepositiveInt Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
code | | 1..1 | CodeableConcept | There are no (further) constraints on this element Element idClaimResponse.error.code Short descriptionError code detailing processing issues DefinitionAn error code, from a specified code system, which details why the claim could not be adjudicated.
RequirementsRequired to convey processing errors.
Data typeCodeableConcept BindingThe adjudication error codes.
Adjudication Error Codes (example) Constraints- ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
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