Data population is similar to a typical predetermination ClaimResponse (where the corresponding Claim.use was set to "predetermination"), with the following key differences:

• in addition to cost and coverage for the requested medication and pharmacy, the responder may also return information about alternative medication + pharmacy combinations. These alternatives are conveyed in one or more ClaimResponse.addItem composites, characterized as independent options using an extension defined in this guide (isAlternative)
• the benefitRestriction extension is used to communicate the level at which the requested drug and pharmacy are covered, as well as alternative drug/pharmacy combinations (using high-level, pre-defined benefit restrictions tailored to the patient's perspective)
• the processNote element can be used to communicate additional textual information related to the cost or coverage of the requested medication, pharmacy or alternative
• alternative pharmacies are communicated using referenced Organization resources
• certain other elements are fixed to values reflecting a medication-related request… ClaimResponse.type = "pharmacy" ClaimResponse.addItem elements are constrained to product identifiers and quantity units of measure describing medications.
  

In this profile, the ClaimResponse references the following supported resources, both of which are profiled in this guide:

• Patient (containing a small amount of identifying information to enable the insurer to locate the patient's records)
• Organization (identifying an alternative pharmacy)
  
  

Must Support elements in this profile

Responding systems

• Responders SHOULD return pricing and coverage information for relevant drug/pharmacy alternatives, in the addItem composite

• Every response must contain either an item composite or an error composite, but not both. The Item composite MUST be populated when sufficient information is received to be able to answer the request. The error composite MUST be populated when the responder cannot complete processing due to insufficient or invalid information in the request

• The benefitRestrictions extension is a conditional element that MUST be populated when the responder is an insurer (or other processor representing the patient's pharmacy benefit). It is not expected to be populated when the responder is a medication pricing source
• The processNote element is a conditional element that MAY be populated when the responder has additional information about costs or coverage related to an .item or .addItem. The noteNumber links an .item or .addItem to its associated processNote
• All elements marked Must Support are essential to communicating patient costs and coverage. The responder MUST ensure that content in these elements is accurate and complete

Client systems

• MUST be able to interpret and convey to users all cost and coverage information returned in the response, as appropriate to the application

• 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
id	SΣ	0..1	id	Unique ClaimResponse Resource Identifier
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	RTPBC Response Identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	Unique RTPBC response ID Example General: 123456
status	?!SΣ	1..1	code	Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	SΣ	1..1	code	Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient	SΣ	1..1	Reference(RTPBC Patient)	Response Patient Information
created	Σ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	Payer ID Example General: 123456
request	SΣ	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	RTPBC Request ID Example General: 123456
outcome	SΣ	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	SΣC	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	SΣ	1..1	decimal	Quantity in Billing Units
unit	SΣ	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote	S	0..*	BackboneElement	Determination Note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Reject Code
display	SΣ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Reject Message
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard
ClaimResponse.use	required	Fixed Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.request.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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			ClaimResponse
id	S	0..1	id	Unique ClaimResponse Resource Identifier
identifier	S	1..*	Identifier	RTPBC Response Identifier
value	S	1..1	string	Unique RTPBC response ID
status	S	1..1	code	Response status Fixed Value: active
type	S	1..1	CodeableConcept	Requested Service Type
coding	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	S	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	S	1..1	code	Processing Mode Fixed Value: predetermination
patient	S	1..1	Reference(RTPBC Patient)	Response Patient Information
insurer	S	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	Payer ID
request	S	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	RTPBC Request ID
outcome	S	1..1	code	Processing Outcome
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	S	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	S	1..1	decimal	Quantity in Billing Units
unit	S	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote	S	0..*	BackboneElement	Determination Note
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Reject Code
display	S	1..1	string	Representation defined by the system
text	S	0..1	string	Reject Message
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	SΣ	0..1	id	Unique ClaimResponse Resource Identifier
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	S	1..*	Identifier	RTPBC Response Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	Unique RTPBC response ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Pharmacy
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient	SΣ	1..1	Reference(RTPBC Patient)	Response Patient Information
created	Σ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organization)	Party responsible for reimbursement
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	Payer ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	Σ	0..1	string	Text alternative for the resource
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SΣ	1..1	Reference(Claim)	Submitter's RTPBC Request ID
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	RTPBC Request ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	Σ	0..1	string	Text alternative for the resource
outcome	SΣ	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition	S	0..1	string	Completed Note
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	S	0..*	BackboneElement	Requested Product and Pharmacy
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
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	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
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	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	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Reference to Priced Pharmacy
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Product Description
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
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	S	1..1	SimpleQuantity	Priced Quantity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Quantity in Billing Units
unit	SΣ	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system	ΣC	0..1	uri	System that defines coded unit form
code	Σ	0..1	code	Coded form of the unit
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	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
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	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
value		0..1	decimal	Non-monetary value
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	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	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	S	0..*	BackboneElement	Determination Note
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	S	1..1	positiveInt	Determination Note Number
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text	S	1..1	string	Determination Note 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	S	0..*	BackboneElement	Error 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
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Reject Code
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Reject Message
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard
ClaimResponse.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype From the FHIR Standard
ClaimResponse.use	required	Fixed Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.insurer.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.request.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.request.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.request.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.provider.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	SΣ	0..1	id	Unique ClaimResponse Resource Identifier
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	S	1..*	Identifier	RTPBC Response Identifier
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	Unique RTPBC response ID Example General: 123456
status	?!SΣ	1..1	code	Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	SΣ	1..1	code	Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient	SΣ	1..1	Reference(RTPBC Patient)	Response Patient Information
created	Σ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	Payer ID Example General: 123456
request	SΣ	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value	SΣ	1..1	string	RTPBC Request ID Example General: 123456
outcome	SΣ	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	SΣC	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	SΣ	1..1	decimal	Quantity in Billing Units
unit	SΣ	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote	S	0..*	BackboneElement	Determination Note
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding	SΣ	1..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Reject Code
display	SΣ	1..1	string	Representation defined by the system
text	SΣ	0..1	string	Reject Message
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard
ClaimResponse.use	required	Fixed Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.request.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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			ClaimResponse
id	S	0..1	id	Unique ClaimResponse Resource Identifier
identifier	S	1..*	Identifier	RTPBC Response Identifier
value	S	1..1	string	Unique RTPBC response ID
status	S	1..1	code	Response status Fixed Value: active
type	S	1..1	CodeableConcept	Requested Service Type
coding	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	S	1..1	string	Representation defined by the system Fixed Value: Pharmacy
use	S	1..1	code	Processing Mode Fixed Value: predetermination
patient	S	1..1	Reference(RTPBC Patient)	Response Patient Information
insurer	S	1..1	Reference(Organization)	Party responsible for reimbursement
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	Payer ID
request	S	1..1	Reference(Claim)	Submitter's RTPBC Request ID
identifier	S	1..1	Identifier	Logical reference, when literal reference is not known
value	S	1..1	string	RTPBC Request ID
outcome	S	1..1	code	Processing Outcome
disposition	S	0..1	string	Completed Note
item	S	0..*	BackboneElement	Requested Product and Pharmacy
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem	S	0..*	BackboneElement	Insurer added line items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
reference	S	1..1	string	Reference to Priced Pharmacy
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Product Description
quantity	S	1..1	SimpleQuantity	Priced Quantity
value	S	1..1	decimal	Quantity in Billing Units
unit	S	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
category	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount	S	1..1	Money	Patient Pay Component Amount
value	S	1..1	decimal	Patient Pay Amount Value
currency	S	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote	S	0..*	BackboneElement	Determination Note
number	S	1..1	positiveInt	Determination Note Number
text	S	1..1	string	Determination Note Text
error	S	0..*	BackboneElement	Error Information
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Reject Code
display	S	1..1	string	Representation defined by the system
text	S	0..1	string	Reject Message
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	SΣ	0..1	id	Unique ClaimResponse Resource Identifier
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	S	1..*	Identifier	RTPBC Response Identifier
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	Unique RTPBC response ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SΣ	1..1	code	Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type	SΣ	1..1	CodeableConcept	Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: pharmacy
display	SΣ	1..1	string	Representation defined by the system Fixed Value: Pharmacy
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SΣ	1..1	code	Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient	SΣ	1..1	Reference(RTPBC Patient)	Response Patient Information
created	Σ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organization)	Party responsible for reimbursement
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	Payer ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	Σ	0..1	string	Text alternative for the resource
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SΣ	1..1	Reference(Claim)	Submitter's RTPBC Request ID
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	Identifier	Logical reference, when literal reference is not known
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣ	1..1	string	RTPBC Request ID Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	Σ	0..1	string	Text alternative for the resource
outcome	SΣ	1..1	code	Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition	S	0..1	string	Completed Note
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	S	0..*	BackboneElement	Requested Product and Pharmacy
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Claim item instance identifier
noteNumber	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Requested Product and Pharmacy Determination
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	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
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	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	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:isAlternative	S	1..1	boolean	Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction	S	0..*	Coding	Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..*	positiveInt	Associated request Item Sequence
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider	S	1..*	Reference(RTPBC Pharmacy Organization)	Priced Pharmacy
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	1..1	string	Reference to Priced Pharmacy
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
productOrService	S	1..1	CodeableConcept	Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Product Description
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
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	S	1..1	SimpleQuantity	Priced Quantity
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Quantity in Billing Units
unit	SΣ	1..1	string	Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system	ΣC	0..1	uri	System that defines coded unit form
code	Σ	0..1	code	Coded form of the unit
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	S	0..*	positiveInt	Determination Note Number
adjudication	S	1..*	BackboneElement	Alternative Product and Pharmacy Determination
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	S	1..1	CodeableConcept	Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount	S	1..1	Money	Patient Pay Component Amount
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
value	SΣ	1..1	decimal	Patient Pay Amount Value
currency	SΣ	1..1	code	Patient Pay Amount Currency Binding: Currencies (required): Currencies
value		0..1	decimal	Non-monetary value
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	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	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	S	0..*	BackboneElement	Determination Note
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	S	1..1	positiveInt	Determination Note Number
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text	S	1..1	string	Determination Note 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	S	0..*	BackboneElement	Error 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
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Reject Code
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Reject Message
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.status	required	Fixed Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type From the FHIR Standard
ClaimResponse.subType	example	ExampleClaimSubTypeCodes http://hl7.org/fhir/ValueSet/claim-subtype From the FHIR Standard
ClaimResponse.use	required	Fixed Value: predetermination http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.insurer.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.insurer.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.request.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.request.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.request.identifier.type	extensible	Identifier Type Codes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard
ClaimResponse.item.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.provider.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.addItem.productOrService	extensible	RTPBCPrescribableProductCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code From this IG
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.quantity.unit	extensible	RtbpcBillingUnitValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit From this IG
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.adjudication.category	required	RtbpcPatientPayTypeValueSet(a valid code from RTPBC Patient Pay Type Code System) http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type From this IG
ClaimResponse.addItem.adjudication.reason	example	AdjudicationReasonCodes http://hl7.org/fhir/ValueSet/adjudication-reason From the FHIR Standard
ClaimResponse.addItem.adjudication.amount.currency	required	Currencies(a valid code from urn:iso:std:iso:4217) http://hl7.org/fhir/ValueSet/currencies From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	preferred	RtbpcErrorCodeValueSet http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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: 11 elements(23 nested mandatory elements)
Must-Support: 58 elements
Fixed: 5 elements

Structures

This structure refers to these other structures:

• RTPBC Patient (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-patient)
• RTPBC Pharmacy Organization (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-pharmacy-organization)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
• http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative

Maturity: 4