This is the set of resources that conform to both FAIS ClaimResponse Profile (https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.ClaimResponse) and FAIS ClaimResponse Profile (https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.ClaimResponse).
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ClaimResponse | 0..* | Response to a claim predetermination or preauthorization dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | ||||||
meta | Σ | 0..1 | Meta | Metadata about the resource ele-1: All FHIR elements must have a @value or children | ||||
language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
identifier | 0..* | Identifier | Business Identifier for a claim response ele-1: All FHIR elements must have a @value or children | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children | ||||
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ?? (extensible): The type or discipline-style of the claim. ele-1: All FHIR elements must have a @value or children | ||||
subType | 0..1 | CodeableConcept | More granular claim type Binding: ?? (example): A more granular claim typecode. ele-1: All FHIR elements must have a @value or children | |||||
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: ?? (required): Claim, preauthorization, predetermination. ele-1: All FHIR elements must have a @value or children | ||||
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services ele-1: All FHIR elements must have a @value or children | ||||
created | Σ | 1..1 | dateTime | Response creation date ele-1: All FHIR elements must have a @value or children | ||||
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children | ||||
requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim ele-1: All FHIR elements must have a @value or children | |||||
request | Σ | 1..1 | Reference(FAIS Claim Profile | #sd-IHE.FAIS.Claim-IHE.FAIS.Claim) | Id of resource triggering adjudication ele-1: All FHIR elements must have a @value or children | ||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ?? (required): The result of the claim processing. ele-1: All FHIR elements must have a @value or children | ||||
disposition | 0..1 | string | Disposition Message ele-1: All FHIR elements must have a @value or children | |||||
preAuthRef | 0..1 | string | Preauthorization reference ele-1: All FHIR elements must have a @value or children | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period ele-1: All FHIR elements must have a @value or children | |||||
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ?? (example): A code for the party to be reimbursed. ele-1: All FHIR elements must have a @value or children | |||||
item | 0..* | BackboneElement | Adjudication for claim line items ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
itemSequence | 1..1 | positiveInt | Claim item instance identifier ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 1..* | BackboneElement | Adjudication details ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
category | 1..1 | CodeableConcept | Type of adjudication information Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. ele-1: All FHIR elements must have a @value or children | |||||
amount | 0..1 | Money | Monetary amount ele-1: All FHIR elements must have a @value or children | |||||
value | 0..1 | decimal | Non-monetary value ele-1: All FHIR elements must have a @value or children | |||||
detail | 0..* | BackboneElement | Adjudication for claim details ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
detailSequence | 1..1 | positiveInt | Claim detail instance identifier ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 1..* | Detail level adjudication details ele-1: All FHIR elements must have a @value or children | ||||||
subDetail | 0..* | BackboneElement | Adjudication for claim sub-details ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 0..* | Subdetail level adjudication details ele-1: All FHIR elements must have a @value or children | ||||||
addItem | 0..* | BackboneElement | Insurer added line items ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
itemSequence | 0..* | positiveInt | Item sequence number ele-1: All FHIR elements must have a @value or children | |||||
detailSequence | 0..* | positiveInt | Detail sequence number ele-1: All FHIR elements must have a @value or children | |||||
subdetailSequence | 0..* | positiveInt | Subdetail sequence number ele-1: All FHIR elements must have a @value or children | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers ele-1: All FHIR elements must have a @value or children | |||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. ele-1: All FHIR elements must have a @value or children | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (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. ele-1: All FHIR elements must have a @value or children | |||||
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ?? (example): Program specific reason codes. ele-1: All FHIR elements must have a @value or children | |||||
serviced[x] | 0..1 | Date or dates of service or product delivery ele-1: All FHIR elements must have a @value or children | ||||||
servicedDate | date | |||||||
servicedPeriod | Period | |||||||
location[x] | 0..1 | Place of service or where product was supplied Binding: ?? (example): Place of service: pharmacy, school, prison, etc. ele-1: All FHIR elements must have a @value or children | ||||||
locationCodeableConcept | CodeableConcept | |||||||
locationAddress | Address | |||||||
locationReference | Reference(Location) | |||||||
quantity | 0..1 | ??, ?? | Count of products or services ele-1: All FHIR elements must have a @value or children | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children | |||||
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |||||
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |||||
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch. ele-1: All FHIR elements must have a @value or children | |||||
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations. ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 1..* | Added items adjudication ele-1: All FHIR elements must have a @value or children | ||||||
detail | 0..* | BackboneElement | Insurer added line details ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. ele-1: All FHIR elements must have a @value or children | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (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. ele-1: All FHIR elements must have a @value or children | |||||
quantity | 0..1 | ??, ?? | Count of products or services ele-1: All FHIR elements must have a @value or children | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children | |||||
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |||||
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 1..* | Added items detail adjudication ele-1: All FHIR elements must have a @value or children | ||||||
subDetail | 0..* | BackboneElement | Insurer added line items ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. ele-1: All FHIR elements must have a @value or children | |||||
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (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. ele-1: All FHIR elements must have a @value or children | |||||
quantity | 0..1 | ??, ?? | Count of products or services ele-1: All FHIR elements must have a @value or children | |||||
unitPrice | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children | |||||
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |||||
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |||||
adjudication | 1..* | Added items detail adjudication ele-1: All FHIR elements must have a @value or children | ||||||
adjudication | 0..* | Header-level adjudication ele-1: All FHIR elements must have a @value or children | ||||||
total | Σ | 0..* | BackboneElement | Adjudication totals ele-1: All FHIR elements must have a @value or children | ||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children | ||||
amount | Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children | ||||
payment | 0..1 | BackboneElement | Payment Details ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
type | 1..1 | CodeableConcept | Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment. ele-1: All FHIR elements must have a @value or children | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues ele-1: All FHIR elements must have a @value or children | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: ?? (example): Payment Adjustment reason codes. ele-1: All FHIR elements must have a @value or children | |||||
date | 0..1 | date | Expected date of payment ele-1: All FHIR elements must have a @value or children | |||||
amount | 1..1 | Money | Payable amount after adjustment ele-1: All FHIR elements must have a @value or children | |||||
identifier | 0..1 | Identifier | Business identifier for the payment ele-1: All FHIR elements must have a @value or children | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None). ele-1: All FHIR elements must have a @value or children | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: ?? (example): The forms codes. ele-1: All FHIR elements must have a @value or children | |||||
form | 0..1 | Attachment | Printed reference or actual form ele-1: All FHIR elements must have a @value or children | |||||
processNote | 0..* | BackboneElement | Note concerning adjudication ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
number | 0..1 | positiveInt | Note instance identifier ele-1: All FHIR elements must have a @value or children | |||||
type | 0..1 | code | display | print | printoper Binding: ?? (required): The presentation types of notes. ele-1: All FHIR elements must have a @value or children | |||||
text | 1..1 | string | Note explanatory text ele-1: All FHIR elements must have a @value or children | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: ?? (preferred): A human language.
ele-1: All FHIR elements must have a @value or children | |||||
communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information ele-1: All FHIR elements must have a @value or children | |||||
insurance | 0..* | BackboneElement | Patient insurance information ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
sequence | 1..1 | positiveInt | Insurance instance identifier ele-1: All FHIR elements must have a @value or children | |||||
focal | 1..1 | boolean | Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children | |||||
coverage | 1..1 | Reference(Coverage) | Insurance information ele-1: All FHIR elements must have a @value or children | |||||
businessArrangement | 0..1 | string | Additional provider contract number ele-1: All FHIR elements must have a @value or children | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results ele-1: All FHIR elements must have a @value or children | |||||
error | 0..* | BackboneElement | Processing errors ele-1: All FHIR elements must have a @value or children | |||||
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | ||||
itemSequence | 0..1 | positiveInt | Item sequence number ele-1: All FHIR elements must have a @value or children | |||||
detailSequence | 0..1 | positiveInt | Detail sequence number ele-1: All FHIR elements must have a @value or children | |||||
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number ele-1: All FHIR elements must have a @value or children | |||||
code | 1..1 | CodeableConcept | Error code detailing processing issues Binding: ?? (example): The adjudication error codes. ele-1: All FHIR elements must have a @value or children | |||||
Documentation for this format |