<status value="draft" /> <description value="To convey the Prior Adjudication details, that will be shared with downstream adjudicators" /> <purpose value="To convey the Prior Adjudication details, that will be shared with downstream adjudicators" /> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="ClaimResponse" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ClaimResponse" /> <derivation value="constraint" /> <differential> <element id="ClaimResponse"> <path value="ClaimResponse" /> <comment value="Usage: This is used to convey the Prior Adjudication details, that will be shared with downstream adjudicators" /> </element> <element id="ClaimResponse.id"> <path value="ClaimResponse.id" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.meta"> <path value="ClaimResponse.meta" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.meta.profile"> <path value="ClaimResponse.meta.profile" /> <comment value="Usage Note: This fixed value is useful to differentiate between the Claim Response profile and the prior calim response profile for validation purposes. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set." /> <max value="1" /> <fixedCanonical value="http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-claim-response-prior" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.identifier"> <path value="ClaimResponse.identifier" /> <slicing> <discriminator> <type value="value" /> <path value="assigner.identifier.type.coding.system" /> </discriminator> <rules value="open" /> </slicing> <comment value="Usage Note: This is an internal reference number assigned to each claim by the processor. As this is a prior claim response this is not required" /> <max value="0" /> </element> <element id="ClaimResponse.status"> <path value="ClaimResponse.status" /> <comment value="Usage Note: Reject claim responses may be included but are still considered active. Example: drug not covered may be included, but patient's coverage expired may not be sent CPHA Mapping: None This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid." /> <fixedCode value="active" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.type"> <path value="ClaimResponse.type" /> <comment value="Usage: Value of "pharmacy" or "professional" to align with the claim type This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.type.coding"> <path value="ClaimResponse.type.coding" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.type.text"> <path value="ClaimResponse.type.text" /> <min value="1" /> <fixedString value="pharmacy" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.subType"> <path value="ClaimResponse.subType" /> <comment value="Conformance Rule: This will be used to convey the "type" of Claim/Claim Response in accordance with the Plan Type. Set value = "public" or "private", "patientAssistedCard" or "unknown". Rationale: This value will be conveyed in downstream claim requests (eg secondary, tertiary), as part of the Prior Claim Response to assist in proper coordination of benefits. This will be mapped from prior claim responses CPHA Map: None: This is a new data element This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type." /> <min value="1" /> <mustSupport value="true" /> <binding> <strength value="example" /> <valueSet value="http://pharmacyeclaims.ca/FHIR/CodeSystem/coverage-type" /> </binding> </element> <element id="ClaimResponse.subType.coding"> <path value="ClaimResponse.subType.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.subType.coding.system"> <path value="ClaimResponse.subType.coding.system" /> <comment value="Usage: Set value = http://pharmacyeclaims.ca/FHIR/CodeSystem/coverage-type The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.subType.coding.code"> <path value="ClaimResponse.subType.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.use"> <path value="ClaimResponse.use" /> <fixedCode value="claim" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.patient"> <path value="ClaimResponse.patient" /> <comment value="Usage Note: The same resource from the request may be included here or just an identifier included CPHA Mapping: None References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository." /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> <targetProfile value="http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-patient" /> </type> <mustSupport value="true" /> </element> <element id="ClaimResponse.patient.reference"> <path value="ClaimResponse.patient.reference" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.created"> <path value="ClaimResponse.created" /> <comment value="CPHA Mapping: Adjudication Date E.01.03" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurer"> <path value="ClaimResponse.insurer" /> <comment value="Usage Note: This may be considered as private in prior adjudication results; howver as this is a mandatory element a display value of "unavailable" may be used. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurer.identifier"> <path value="ClaimResponse.insurer.identifier" /> <comment value="Usage Note: Where the insurer identifier may be shared with downstream adjudicators, this may be included. Otherwise the display ("unavailable) must be present. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any)." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurer.identifier.system"> <path value="ClaimResponse.insurer.identifier.system" /> <min value="1" /> <fixedUri value="http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurer.identifier.value"> <path value="ClaimResponse.insurer.identifier.value" /> <comment value="CPHA Mapping: IIN ( Issuer Identification Number) A.01.01 If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurer.display"> <path value="ClaimResponse.insurer.display" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.request"> <path value="ClaimResponse.request" /> <comment value="Usage Note: This field is limited to a single identifier. The number assigned, by the provider, to the transaction to which this response applies. This must be present when conveying Prior Claim Intervention Codes (extension) CPHA Mapping: Trace Number B.23.03 (in display) References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.request.extension:PriorClaimInterventionCodes"> <path value="ClaimResponse.request.extension" /> <sliceName value="PriorClaimInterventionCodes" /> <definition value="Intervention codes from a prior claim" /> <comment value="Usage Rule: For prior claims, this is the list of intervention codes contained in the prior claim. This is necessary as the prior adjudicator may support a different set of intervention codes as they use a different protocol (eg RAMQ, NeCST, CPHA3). The code system (assigning authority, which align to the protocol, eg RAMQ, NeCST) and the intervention/exception code. The display name associated with the code t is also recommended." /> <type> <code value="Extension" /> <profile value="http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-prior-intervention-codes" /> </type> <isModifier value="false" /> </element> <element id="ClaimResponse.request.identifier"> <path value="ClaimResponse.request.identifier" /> <comment value="Usage Note: This will be the Claim.identifier (slice Claim-identifier) from the request message. As this is a prior claim response, this will only be used under certain conditions as established by the implementer. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any)." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.request.identifier.system"> <path value="ClaimResponse.request.identifier.system" /> <min value="1" /> <fixedUri value="http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.request.identifier.value"> <path value="ClaimResponse.request.identifier.value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.request.display"> <path value="ClaimResponse.request.display" /> <comment value="Usage Note: This is limited to 6N in order to support backward compatibility to CPHA This will be the trace number from the Claim Request.identifier.value The number assigned, by the provider, to the transaction to which this response applies. This is limited to 6N, in order to maintain backward compatibility with CPHA. This is optional as the Trace number can be deprecated once all implementations natively support FHIR. CPHA Mapping: Trace Number B.23.03 This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.outcome"> <path value="ClaimResponse.outcome" /> <comment value="Usage Note: This can be set to "complete" or "error" CPHA Map: E.05.03 Response Status The decision as set in the prior adjudication result. A value of "A" (accepted) or "R" rejected will be set in CPHA, which maps to "complete" or "error". The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete)." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.disposition"> <path value="ClaimResponse.disposition" /> <comment value="CPHA Map: Response Status E.05.03 Usage: This indicates the status of the claim response or prior claim response and is crucial for downstream payors to understand the outcome of the adjudication. Set values = A or B or C, . as follows: A=accepted as transmitted - no adjustments B=accepted with Rx price adjustment R=rejected claim/reversal Note that FHIR strings SHALL NOT exceed 1MB in size" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payeeType"> <path value="ClaimResponse.payeeType" /> <comment value="Usage Rule: Determines who the adjudicator/insurer will issue payment to. Set value = "subscriber" or "provider". The pay subscriber option may be used if the network is down, and when the pharmacy has collected from the patient and is submitting on their behalf. Usage Note: This may not be present if the claim was rejected; otherwise this must be populated CPHA Mapping: Transaction code E,03,03. Value of "provider" maps to 51=response to a pay provider claim for real-time adjudication Value of "subscriber" maps to 54=response to a pay cardholder claim If value = subscriber, maps to CPHA Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payeeType.coding"> <path value="ClaimResponse.payeeType.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payeeType.coding.system"> <path value="ClaimResponse.payeeType.coding.system" /> <min value="1" /> <fixedUri value="http://terminology.hl7.org/CodeSystem/payeetype" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payeeType.coding.code"> <path value="ClaimResponse.payeeType.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item"> <path value="ClaimResponse.item" /> <comment value="Usage Note: Identifies the item submitted and the associated adjudication results. This is a sub-set of the claim response items returned." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.itemSequence"> <path value="ClaimResponse.item.itemSequence" /> <comment value="Usage Note: This is the claim.item.sequence from the request message. Currently, this will be a value of "1". CPHA Mapping: None 32 bit number; for values larger than this, use decimal" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication"> <path value="ClaimResponse.item.adjudication" /> <slicing> <discriminator> <type value="value" /> <path value="category.coding.code" /> </discriminator> <rules value="open" /> </slicing> <comment value="Usage Note: Only pertinent adjudication details for downstream payors should be included." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.category"> <path value="ClaimResponse.item.adjudication.category" /> <comment value="Usage: This will indicate the type of adjudication, eg DrugCost, Cost Upcharge, etc. CPHA3: Used in field mapping For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc." /> <mustSupport value="true" /> <binding> <strength value="extensible" /> </binding> </element> <element id="ClaimResponse.item.adjudication.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.category.coding.system"> <path value="ClaimResponse.item.adjudication.category.coding.system" /> <fixedUri value="http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.category.coding.display"> <path value="ClaimResponse.item.adjudication.category.coding.display" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.reason"> <path value="ClaimResponse.item.adjudication.reason" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication.value"> <path value="ClaimResponse.item.adjudication.value" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DrugCost"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="DrugCost" /> <comment value="CPHA Map: E.08.03 Drug Cost/Product Value" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DrugCost.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DrugCost.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DrugCost.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="DrugCost" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DrugCost.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CostUpcharge"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="CostUpcharge" /> <comment value="CPHA Map: E.09.03 Cost Upcharge" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CostUpcharge.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CostUpcharge.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CostUpcharge.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="Upcharge" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CostUpcharge.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:GenericIncentive"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="GenericIncentive" /> <comment value="Usage: No known use cases; this is only present for backward compatibility but not expected to be used. CPHA Map: E.10.03 Generic Incentive" /> <max value="1" /> </element> <element id="ClaimResponse.item.adjudication:GenericIncentive.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:GenericIncentive.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:GenericIncentive.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="GenericIncentive" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:GenericIncentive.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ProfessionalFee"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="ProfessionalFee" /> <comment value="CPHA: E.12.03 Professional Fee" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ProfessionalFee.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ProfessionalFee.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ProfessionalFee.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="ProfFee" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ProfessionalFee.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CompoundingCharge"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="CompoundingCharge" /> <comment value="CPHA Map: E.13.03 Compounding Charge" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CompoundingCharge.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CompoundingCharge.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CompoundingCharge.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="CompoundingCharge" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CompoundingCharge.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialServiceFee"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="SpecialServiceFee" /> <comment value="CPHA Map: E.14.03 Special Services Fee" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialServiceFee.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialServiceFee.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialServiceFee.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="SSF" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialServiceFee.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoPayToCollect"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="CoPayToCollect" /> <comment value="Usage: The co pay amount which the provider collects from the beneficiary for a specific claim. This refers to "co pay" as defined in the carrier's benefit brochure. CPHA Map: Copay to Collect E.15.03 Optional D6" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoPayToCollect.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoPayToCollect.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoPayToCollect.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="Co-Pay" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoPayToCollect.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DeductibleToCollect"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="DeductibleToCollect" /> <comment value="Usage: The deductible amount which the provider collects from the beneficiary for a specific claim. This refers to "deductible" as defined in the carrier's benefit brochure. CPHA Map: Deductible to Collect E.16.03 Optional D6" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DeductibleToCollect.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DeductibleToCollect.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DeductibleToCollect.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="Deductible" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:DeductibleToCollect.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoInsuranceToCollect"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="CoInsuranceToCollect" /> <comment value="Usage: The co-insurance amount which the provider collects from the beneficiary for a specific claim. This refers to "co-insurance" as defined in the carrier's benefit brochure. CPHA Map: Co-Insurance to Collect E.17.03 Optional D6" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoInsuranceToCollect.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoInsuranceToCollect.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoInsuranceToCollect.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="CoInsurance" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:CoInsuranceToCollect.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthTotalQuantityDispenseAccumulated"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="SpecialAuthTotalQuantityDispenseAccumulated" /> <comment value="Usage: Total Quantity Dispense Accumulated. The total number of pills "adjudicated" for a special auth number. An Adjudicator authorizes the number of pills against a special auth number; the dispenses may occur across several pharmacies. This accumulated total is returned as part of the adjudication result as informational data. Usage: Used in NFLD today and may be used by other provinces. CPHA Mapping: None; this is a new data element" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthTotalQuantityDispenseAccumulated.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthTotalQuantityDispenseAccumulated.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <fixedCoding> <code value="SADispenseAccumulated" /> </fixedCoding> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthTotalQuantityDispenseAccumulated.value"> <path value="ClaimResponse.item.adjudication.value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="SpecialAuthRemainingQuant" /> <comment value="Usage: Total special authorized quantity remaining on a prescription after this dispense (across all prescriptions). Recognizing that the quantity is relating to the unit and the strength of the product, this may also be specified. eg 10 tabs of 5mg strength is equivalent to 20 tabs and 2.5 mg. This will include the quantity and unit. Rationale: The pharmacy does not currently have access to this data Conformance Rule: The quantity remaining must be based upon the DIN strength in the claim request. Usage Note: . If there is no special authorization, this field will not be used. If the adjudicator is not currently returning this information, this may be left blank." /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant.extension"> <path value="ClaimResponse.item.adjudication.extension" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant.extension:AuthQuantityUnitBasedOnStrength"> <path value="ClaimResponse.item.adjudication.extension" /> <sliceName value="AuthQuantityUnitBasedOnStrength" /> <comment value="Usage: Total special authorized quantity remaining on a prescription after this dispense (across all prescriptions). Recognizing that the quantity is relating to the unit and the strength of the product, this may also be specified. eg 10 tabs of 5mg strength is equivalent to 20 tabs and 2.5 mg. This will include the quantity and unit. Rationale: The pharmacy does not currently have access to this data Conformance Rule: The quantity remaining must be based upon the DIN strength in the claim request. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone." /> <min value="1" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/Ext-AuthQuantityBasedOnUnit" /> </type> <mustSupport value="true" /> <isModifier value="false" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant.category"> <path value="ClaimResponse.item.adjudication.category" /> <fixedCodeableConcept> <coding> <code value="SARemainingQuantity" /> </coding> </fixedCodeableConcept> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <fixedCoding> <code value="SARemainingQuantity" /> </fixedCoding> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthRemainingQuant.value"> <path value="ClaimResponse.item.adjudication.value" /> <comment value="Usage Note: The extension AuthQuantityUnitBasedOnStregth will include the value (quantity and unit) so this is not required. For example: eligible percentage or co-payment percentage." /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthApprovedDaysSupply"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="SpecialAuthApprovedDaysSupply" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthApprovedDaysSupply.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthApprovedDaysSupply.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <fixedCoding> <code value="SADaysSupply" /> </fixedCoding> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthApprovedDaysSupply.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:SpecialAuthApprovedDaysSupply.value"> <path value="ClaimResponse.item.adjudication.value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="PertinentAdjudicationDetails" /> <comment value="Usage Note: This field allows the first payor to pass on pertinent information to a secondary carrier. It allows for coding or textual data to be sent which may be useful as use cases evolve. Conformance Rule: Only used by implementers with a specific use case, eg in BC today for BC does Usage Note: In BC, data is passed in a response code, which is then transposed into a downstream claim request in the special auth field. This field removes the requirement for the vendor to transposed the data. It is instead placed here. CPHA Mapping: None. Today, data is returned from the first payor in BC as a response code; this is then transposed into the request message for the secondary carrier." /> <max value="20" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.category"> <path value="ClaimResponse.item.adjudication.category" /> <comment value="Usage Note: A coded value of "BCCodes" must be used for the existing use case. Other codes will be assigned as use cases evolve." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.reason"> <path value="ClaimResponse.item.adjudication.reason" /> <comment value="Usage Note: Adjudicators will used codes to convey the desired information. The codes will be determined by each implementer. Example: BC has existing codes that may be used. For example may indicate that the funds for this benefit type have been exhausted." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.reason.coding"> <path value="ClaimResponse.item.adjudication.reason.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.reason.coding.code"> <path value="ClaimResponse.item.adjudication.reason.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.amount"> <path value="ClaimResponse.item.adjudication.amount" /> <mustSupport value="false" /> </element> <element id="ClaimResponse.item.adjudication:PertinentAdjudicationDetails.value"> <path value="ClaimResponse.item.adjudication.value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="ResponseCodes" /> <comment value="Usage: To capture the response codes returned by the 1st /upstream payer. For example, if a drug where 1st payer in Quebec is returned as having been processed but 0$ paid, the error message is helpful to the secondary payor. Usage: These codes will be passed on to downstream payors." /> <max value="20" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.category"> <path value="ClaimResponse.item.adjudication.category" /> <comment value="Usage Note: Set value = "ResponseCode" In future, more granular categories may be defined. For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, DUR, etc." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.reason"> <path value="ClaimResponse.item.adjudication.reason" /> <comment value="CPHA Map: Response Codes E.06.03 A/N10 Usage Note: Codes to define responses that identify errors and other reasons that may cause the claim(s) to be altered or rejected. In CPHA, the Field length of 10 will accommodate 5 response codes per claim. In FHIR, this is a list with a practical maximum of 20 codes. Note: error codes may be moved out of the repsonse codes For example may indicate that the funds for this benefit type have been exhausted." /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.reason.coding"> <path value="ClaimResponse.item.adjudication.reason.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.reason.coding.system"> <path value="ClaimResponse.item.adjudication.reason.coding.system" /> <comment value="Usage Note: Usage Note: This is recommended for use, but optional. All coding systems should be specified to identify the source system, including http://pharmacyeclaims.ca/FHIR/CodeSystem/CPHA3-response-codes. Other code systems, such as RAMQ and BC will also be supported. Refer to terminology section of this specification. Usage Note: This is not mandatory as it will only be required when code sets are not synchronized which may happen over time as codes become deprecated or new codes are added. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ResponseCodes.reason.coding.code"> <path value="ClaimResponse.item.adjudication.reason.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes"> <path value="ClaimResponse.item.adjudication" /> <sliceName value="ClinicalAlertCodes" /> <max value="20" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.category"> <path value="ClaimResponse.item.adjudication.category" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.category.coding"> <path value="ClaimResponse.item.adjudication.category.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.category.coding.code"> <path value="ClaimResponse.item.adjudication.category.coding.code" /> <min value="1" /> <fixedCode value="ClinicalCode" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.reason"> <path value="ClaimResponse.item.adjudication.reason" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.reason.coding"> <path value="ClaimResponse.item.adjudication.reason.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.reason.coding.system"> <path value="ClaimResponse.item.adjudication.reason.coding.system" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.reason.coding.code"> <path value="ClaimResponse.item.adjudication.reason.coding.code" /> <comment value="Usage: Alert Code Note that FHIR strings SHALL NOT exceed 1MB in size" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.item.adjudication:ClinicalAlertCodes.reason.text"> <path value="ClaimResponse.item.adjudication.reason.text" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment"> <path value="ClaimResponse.payment" /> <comment value="Usage: The conveyes (in amount) the total amount payable, by the insurer, to the provider for product, services and taxes for a specific claim or to the patient. Refer to the payee type to understand who the payment was directed to. This includes all amounts in the "ClaimResponse.item.adjudication" section (eg DrugCostProductValue, CostUpcharge, GenericIncentive.. etc) less any amount paid by the beneficiary Usage: There is no size restriction on this dollar amount field" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.type"> <path value="ClaimResponse.payment.type" /> <comment value="CPHA Mapping: None. Usage: This amount must be derived. If the paid amount is less than submitted, value = "partial", else "complete" Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination." /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.type.coding"> <path value="ClaimResponse.payment.type.coding" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.type.coding.system"> <path value="ClaimResponse.payment.type.coding.system" /> <comment value="Usage: This is a fixed value The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously." /> <min value="1" /> <fixedUri value="http://hl7.org/fhir/ValueSet/ex-paymenttype" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.type.coding.code"> <path value="ClaimResponse.payment.type.coding.code" /> <comment value="Usage: Set value = "partial" or "complete" Note that FHIR strings SHALL NOT exceed 1MB in size" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.amount"> <path value="ClaimResponse.payment.amount" /> <comment value="Usage: The total amount payable, by the insurer, to the provider or patient/insured party for product, services and taxes for a specific claim. This includes all amounts in the "ClaimResponse.item.adjudication" section (eg DrugCostProductValue, CostUpcharge, GenericIncentive.. etc) less any amount paid by the beneficiary. Usage: There is no size restriction on this dollar amount field CPHA Mapping: Plan Pays E.19.03 D6" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.payment.amount.value"> <path value="ClaimResponse.payment.amount.value" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote"> <path value="ClaimResponse.processNote" /> <comment value="Usage: Detailed response information. Adjudicators to determine what if any process notes should be included for purposes of sharing with downstream adjudicators. Conformance Rule: A maximum of 1000 characters may be returned for each note Conformance Rule: A maximum of 10 notes can be returned; this allows for a given note to be returned in both english and french and therefore allows up to 20 instances. Conformance Rule: Where possible adjudicators must return both english and french as this allows the vendor to display the note in the language of the user. Conformance Rule: Vendors must co-relate french and english notes by assigning the same processNote.number Conformance Rule: When the adjudicator does not know whether a note is french or english, the language.text must contain a value of "unknown". CPHA Map: Message Data Lines 1,2,3 E.20.03, E.21.03, E.22.03 A/N40" /> <max value="20" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.number"> <path value="ClaimResponse.processNote.number" /> <comment value="Usage Note: When an adjudicator returns the same note in both english and french, this number must be used to co-relate the notes. Vendors must co-relate french and english notes by assigning the same processNote.number 32 bit number; for values larger than this, use decimal" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.type"> <path value="ClaimResponse.processNote.type" /> <comment value="Usage Notes: Systems that natively support FHIR must support this CPHA Mapping: None Note that FHIR strings SHALL NOT exceed 1MB in size" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.text"> <path value="ClaimResponse.processNote.text" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.language"> <path value="ClaimResponse.processNote.language" /> <comment value="Conformance Rule: This must be populated with a code of "en" for English or "fr" for French, OR, if unknown, do not use a code and instead populate the text value with "unknown". Where possible, both english and french messages should be included CPHA Mapping: None. New requirement Only required if the language is different from the resource language." /> <min value="1" /> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="http://hl7.org/fhir/ValueSet/all-languages" /> </binding> </element> <element id="ClaimResponse.processNote.language.coding"> <path value="ClaimResponse.processNote.language.coding" /> <comment value="Usage: Either system+ code must be present (for en and fr), or text must have a value of "unknown". Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true." /> <max value="1" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.language.coding.system"> <path value="ClaimResponse.processNote.language.coding.system" /> <fixedUri value="urn:ietf:bcp:47" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.language.coding.code"> <path value="ClaimResponse.processNote.language.coding.code" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.processNote.language.text"> <path value="ClaimResponse.processNote.language.text" /> <mustSupport value="true" /> </element> <element id="ClaimResponse.insurance"> <path value="ClaimResponse.insurance" /> <comment value="Usage Note: When used in a claim response, this is not required as this resource is referenced through the coverage resource in the primary claim response. When used in a downstream laim request, this is also referenced through the coverage details in the request. All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim." /> <max value="0" /> </element> </differential> </StructureDefinition>