Da Vinci - Coverage Requirements Discovery
1.1.0-ballot - STU 1.1 United States of America flag

Da Vinci - Coverage Requirements Discovery, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 1.1.0-ballot). This version is based on the current content of https://github.com/HL7/davinci-crd/ and changes regularly. See the Directory of published versions

Resource Profile: ClaimResponse

Official URL: http://hl7.org/fhir/us/davinci-crd/StructureDefinition/profile-claimresponse Version: 1.1.0-ballot
Draft as of 2020-11-09 Computable Name: ClaimResponse

This profile specifies constraints on ClaimResponse resource to reflect the contents of a pro-active prior authorization returned via a card

Usage


CRD Clients SHALL use this profile to convey unsolicited prior authorizations stemming from planned orders.

Refer to the section on Pre-emptive Prior Authorization cards in the formal specification for more information.

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClaimResponse

Summary

Mandatory: 2 elements
Must-Support: 64 elements
Fixed Value: 3 elements
Prohibited: 2 elements

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponsePrior authorization
... status S1..1codeactive | cancelled | draft | entered-in-error
Fixed Value: active
... type S1..1CodeableConceptMore granular claim type
... use S1..1codeclaim | preauthorization | predetermination
Fixed Value: preauthorization
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType S0..1CodeableConceptParty to be paid any benefits payable
... addItem S1..*BackboneElementInsurer added line items
.... provider S0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
.... modifier S0..*CodeableConceptService/Product billing modifiers
.... programCode S0..*CodeableConceptProgram the product or service is provided under
.... location[x] S0..1CodeableConcept, Address, Reference(Location)Place of service or where product was supplied
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor S0..1decimalPrice scaling factor
.... net S0..1MoneyTotal item cost
.... bodySite S0..1CodeableConceptAnatomical location
.... subSite S0..*CodeableConceptAnatomical sub-location
.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdded items adjudication
..... category S1..1CodeableConceptType of adjudication information
..... reason S0..1CodeableConceptExplanation of adjudication outcome
..... amount S0..1MoneyMonetary amount
..... value S0..1decimalNon-monetary value
.... detail S0..*BackboneElementInsurer added line details
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
..... modifier S0..*CodeableConceptService/Product billing modifiers
..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice S0..1MoneyFee, charge or cost per item
..... factor S0..1decimalPrice scaling factor
..... net S0..1MoneyTotal item cost
..... noteNumber S0..*positiveIntApplicable note numbers
..... adjudication S1..*BackboneElementAdded items detail adjudication
...... category S1..1CodeableConceptType of adjudication information
...... reason S0..1CodeableConceptExplanation of adjudication outcome
...... amount S0..1MoneyMonetary amount
...... value S0..1decimalNon-monetary value
..... subDetail S0..*BackboneElementInsurer added line items
...... productOrService S1..1CodeableConceptBilling, service, product, or drug code
...... modifier S0..*CodeableConceptService/Product billing modifiers
...... quantity S0..1SimpleQuantityCount of products or services
...... unitPrice S0..1MoneyFee, charge or cost per item
...... factor S0..1decimalPrice scaling factor
...... net S0..1MoneyTotal item cost
...... noteNumber S0..*positiveIntApplicable note numbers
...... adjudication S1..*BackboneElementAdded items detail adjudication
....... category S1..1CodeableConceptType of adjudication information
....... reason S0..1CodeableConceptExplanation of adjudication outcome
....... amount S0..1MoneyMonetary amount
....... value S0..1decimalNon-monetary value
... total S0..*BackboneElementAdjudication totals
.... category S1..1CodeableConceptType of adjudication information
.... amount S1..1MoneyFinancial total for the category
... payment 0..0
... fundsReserve S0..1CodeableConceptFunds reserved status
... processNote S0..*BackboneElementNote concerning adjudication
.... number S0..1positiveIntNote instance identifier
.... type S0..1codedisplay | print | printoper
.... text S1..1stringNote explanatory text
.... language S0..1CodeableConceptLanguage of the text
... insurance S0..*BackboneElementPatient insurance information
.... sequence S1..1positiveIntInsurance instance identifier
.... focal S1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(Coverage)Insurance information
... error 0..0

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponsePrior authorization
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


Fixed Value: complete
... disposition 0..1stringDisposition Message
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType S0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem S1..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider S0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode S0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor S0..1decimalPrice scaling factor
.... net S0..1MoneyTotal item cost
.... bodySite S0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite S0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdded items adjudication
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason S0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount S0..1MoneyMonetary amount
..... value S0..1decimalNon-monetary value
.... detail S0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice S0..1MoneyFee, charge or cost per item
..... factor S0..1decimalPrice scaling factor
..... net S0..1MoneyTotal item cost
..... noteNumber S0..*positiveIntApplicable note numbers
..... adjudication S1..*BackboneElementAdded items detail adjudication
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason S0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount S0..1MoneyMonetary amount
...... value S0..1decimalNon-monetary value
..... subDetail S0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity S0..1SimpleQuantityCount of products or services
...... unitPrice S0..1MoneyFee, charge or cost per item
...... factor S0..1decimalPrice scaling factor
...... net S0..1MoneyTotal item cost
...... noteNumber S0..*positiveIntApplicable note numbers
...... adjudication S1..*BackboneElementAdded items detail adjudication
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
....... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason S0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount S0..1MoneyMonetary amount
....... value S0..1decimalNon-monetary value
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total SΣ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category SΣ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount SΣ1..1MoneyFinancial total for the category
... fundsReserve S0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote S0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number S0..1positiveIntNote instance identifier
.... type S0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text S1..1stringNote explanatory text
.... language S0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance S0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence S1..1positiveIntInsurance instance identifier
.... focal S1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponsePrior authorization
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type Σ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... preAuthRef 1..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... addItem 1..*BackboneElementInsurer added line items
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdded items adjudication
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementInsurer added line details
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*BackboneElementAdded items detail adjudication
...... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount 0..1MoneyMonetary amount
...... value 0..1decimalNon-monetary value
..... subDetail 0..*BackboneElementInsurer added line items
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*BackboneElementAdded items detail adjudication
....... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

....... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

....... amount 0..1MoneyMonetary amount
....... value 0..1decimalNon-monetary value
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... insurance 0..*BackboneElementPatient insurance information
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information

doco Documentation for this format

This structure is derived from ClaimResponse

Summary

Mandatory: 2 elements
Must-Support: 64 elements
Fixed Value: 3 elements
Prohibited: 2 elements

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponsePrior authorization
... status S1..1codeactive | cancelled | draft | entered-in-error
Fixed Value: active
... type S1..1CodeableConceptMore granular claim type
... use S1..1codeclaim | preauthorization | predetermination
Fixed Value: preauthorization
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType S0..1CodeableConceptParty to be paid any benefits payable
... addItem S1..*BackboneElementInsurer added line items
.... provider S0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
.... modifier S0..*CodeableConceptService/Product billing modifiers
.... programCode S0..*CodeableConceptProgram the product or service is provided under
.... location[x] S0..1CodeableConcept, Address, Reference(Location)Place of service or where product was supplied
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor S0..1decimalPrice scaling factor
.... net S0..1MoneyTotal item cost
.... bodySite S0..1CodeableConceptAnatomical location
.... subSite S0..*CodeableConceptAnatomical sub-location
.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdded items adjudication
..... category S1..1CodeableConceptType of adjudication information
..... reason S0..1CodeableConceptExplanation of adjudication outcome
..... amount S0..1MoneyMonetary amount
..... value S0..1decimalNon-monetary value
.... detail S0..*BackboneElementInsurer added line details
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
..... modifier S0..*CodeableConceptService/Product billing modifiers
..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice S0..1MoneyFee, charge or cost per item
..... factor S0..1decimalPrice scaling factor
..... net S0..1MoneyTotal item cost
..... noteNumber S0..*positiveIntApplicable note numbers
..... adjudication S1..*BackboneElementAdded items detail adjudication
...... category S1..1CodeableConceptType of adjudication information
...... reason S0..1CodeableConceptExplanation of adjudication outcome
...... amount S0..1MoneyMonetary amount
...... value S0..1decimalNon-monetary value
..... subDetail S0..*BackboneElementInsurer added line items
...... productOrService S1..1CodeableConceptBilling, service, product, or drug code
...... modifier S0..*CodeableConceptService/Product billing modifiers
...... quantity S0..1SimpleQuantityCount of products or services
...... unitPrice S0..1MoneyFee, charge or cost per item
...... factor S0..1decimalPrice scaling factor
...... net S0..1MoneyTotal item cost
...... noteNumber S0..*positiveIntApplicable note numbers
...... adjudication S1..*BackboneElementAdded items detail adjudication
....... category S1..1CodeableConceptType of adjudication information
....... reason S0..1CodeableConceptExplanation of adjudication outcome
....... amount S0..1MoneyMonetary amount
....... value S0..1decimalNon-monetary value
... total S0..*BackboneElementAdjudication totals
.... category S1..1CodeableConceptType of adjudication information
.... amount S1..1MoneyFinancial total for the category
... payment 0..0
... fundsReserve S0..1CodeableConceptFunds reserved status
... processNote S0..*BackboneElementNote concerning adjudication
.... number S0..1positiveIntNote instance identifier
.... type S0..1codedisplay | print | printoper
.... text S1..1stringNote explanatory text
.... language S0..1CodeableConceptLanguage of the text
... insurance S0..*BackboneElementPatient insurance information
.... sequence S1..1positiveIntInsurance instance identifier
.... focal S1..1booleanCoverage to be used for adjudication
.... coverage S1..1Reference(Coverage)Insurance information
... error 0..0

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..*ClaimResponsePrior authorization
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages: A human language.

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse creation date
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


Fixed Value: complete
... disposition 0..1stringDisposition Message
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
... payeeType S0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem S1..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..*positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider S0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode S0..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] S0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity S0..1SimpleQuantityCount of products or services
.... unitPrice S0..1MoneyFee, charge or cost per item
.... factor S0..1decimalPrice scaling factor
.... net S0..1MoneyTotal item cost
.... bodySite S0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite S0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber S0..*positiveIntApplicable note numbers
.... adjudication S1..*BackboneElementAdded items adjudication
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

..... reason S0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount S0..1MoneyMonetary amount
..... value S0..1decimalNon-monetary value
.... detail S0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity S0..1SimpleQuantityCount of products or services
..... unitPrice S0..1MoneyFee, charge or cost per item
..... factor S0..1decimalPrice scaling factor
..... net S0..1MoneyTotal item cost
..... noteNumber S0..*positiveIntApplicable note numbers
..... adjudication S1..*BackboneElementAdded items detail adjudication
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... category S1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... reason S0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... amount S0..1MoneyMonetary amount
...... value S0..1decimalNon-monetary value
..... subDetail S0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService S1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier S0..*CodeableConceptService/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity S0..1SimpleQuantityCount of products or services
...... unitPrice S0..1MoneyFee, charge or cost per item
...... factor S0..1decimalPrice scaling factor
...... net S0..1MoneyTotal item cost
...... noteNumber S0..*positiveIntApplicable note numbers
...... adjudication S1..*BackboneElementAdded items detail adjudication
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
....... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized