QI-Core Implementation Guide
7.0.2 - STU 7

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

## Resource Profile: QICore ClaimResponse

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse | Version: 7.0.2
Standards status: Trial-use | Maturity Level: 4 | Computable Name: QICoreClaimResponse
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The QI-Core ClaimResponse profile is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient. It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the ClaimResponse resource when using this profile

"Must Have", "QI Elements" and "primary code path" are defined in the QI-Core Must Support section.
QI Elements:

- request: (QI) Id of resource triggering adjudication
- requestor: (QI) Party responsible for the claim
- patient: (QI) The recipient of the products and services
- created: (QI) Response creation date
- status: (QI) active | cancelled | draft | entered-in-error
- use: (QI) claim | preauthorization | predetermination
- item: (QI) Adjudication for claim line items
- type: (QI) More granular claim type
- insurer: (QI) Party responsible for reimbursement

Primary code path: type
(PCPath) This element is the primary code path for this resource CQL Retrieve
Usage

See the patterns page for implementation and usage patterns.

### Examples

Preauthorization Vision ClaimResponse Example

Usages:

- Examples for this Profile: ClaimResponse/example

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
amount |  | 0..1 | Money | (QI) Monetary amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | error | ClaimResponse | 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 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
amount |  | 0..1 | Money | (QI) Monetary amount
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | (QI) Claim detail instance identifier
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | (QI) Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | (QI) Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | example | AdjudicationError | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | error | ClaimResponse | 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 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements(3 nested mandatory elements)
Fixed: 2 elements

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
- QICore Claim (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim)

Maturity: 4

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
amount |  | 0..1 | Money | (QI) Monetary amount
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | error | ClaimResponse | 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 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
amount |  | 0..1 | Money | (QI) Monetary amount
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | (QI) Claim detail instance identifier
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | (QI) active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | Σ | 1..1 | CodeableConcept | (QI) More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | (QI) claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: preauthorization
patient | Σ | 1..1 | Reference(QICore Patient) | (QI) The recipient of the products and services
created | Σ | 1..1 | dateTime | (QI) Response creation date
insurer | Σ | 1..1 | Reference(QICore Organization) | (QI) Party responsible for reimbursement
requestor |  | 0..1 | Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) | (QI) Party responsible for the claim
request | Σ | 0..1 | Reference(QICore Claim) | (QI) Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 0..* | BackboneElement | (QI) Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | (QI) Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: AdjudicationValueCodes (example): The adjudication codes. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | (QI) Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | (QI) Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/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..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📦4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | example | AdjudicationError | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | 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 | error | ClaimResponse | 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 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements(3 nested mandatory elements)
Fixed: 2 elements

Structures

This structure refers to these other structures:

- QICore Patient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICore Organization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICore Practitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICore PractitionerRole (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitionerrole)
- QICore Claim (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claim)

Maturity: 4

Other representations of profile: CSV, Excel, Schematron