Consumer Real-Time Pharmacy Benefit Check FHIR IG
2.0.0-ballot - STU 2 Ballot

Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions

## Resource Profile: RTPBC Response Using ClaimResponse - Detailed Descriptions

Page standards status: Trial-use | Maturity Level: 2

Definitions for the rtpbc-response-claimresponse resource profile

- Key Elements Table
- Differential Table
- Snapshot Table

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
Definition | This resource provides the adjudication details from the processing of a Claim resource.
Short | Response to a claim predetermination or preauthorization
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Remittance Advice
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) 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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.id
Definition | Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Unique ClaimResponse Resource IdentifierLogical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id string
Is Modifier | false
Must Support | true
Summary | true
Label | Unique ClaimResponse Resource Identifier
4. ClaimResponse.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. ClaimResponse.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. ClaimResponse.identifier
Definition | A unique identifier assigned to this claim response.
Short | RTPBC Response IdentifierBusiness Identifier for a claim response
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..*
Type | Identifier
Is Modifier | false
Must Support | true
Summary | false
Requirements | Allows claim responses to be distinguished and referenced.
Label | RTPBC Response Identifier
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ClaimResponse.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.identifier.value
Definition | An identifier for each RTPBC response that is assigned by and unique to the reponder The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | Unique RTPBC response IDThe value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Unique RTPBC response ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ClaimResponse.status
Definition | The status of this response (active) The status of the resource instance.
Short | Response statusactive | cancelled | draft | entered-in-error
Comments | Value is always 'active' This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Label | Response status
Fixed Value | `active`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ClaimResponse.type
Definition | The type of service for which pricing and coverage predetermination is being requested A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | Requested Service TypeMore granular claim type
Comments | Value is always 'pharmacy' This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes http://hl7.org/fhir/ValueSet/claim-type|4.0.1 (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Label | Requested Service Type
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. ClaimResponse.type.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 10..1*
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.type.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 10..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Fixed Value | `http://terminology.hl7.org/CodeSystem/claim-type`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ClaimResponse.type.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Symbol in syntax defined by the system
Control | 10..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Fixed Value | `pharmacy`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ClaimResponse.type.coding.display
Definition | A representation of the meaning of the code in the system, following the rules of the system.
Short | Representation defined by the system
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Fixed Value | `Pharmacy`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ClaimResponse.use
Definition | The mode of processing being performed by the payer/PBM A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | Processing Modeclaim | preauthorization | predetermination
Comments | Value is always 'predetermination'
Control | 1..1
Binding | The codes SHALL be taken from Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Claim, preauthorization, predetermination.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Label | Processing Mode
Fixed Value | `predetermination`
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ClaimResponse.patient
Definition | Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
Short | Response Patient InformationThe recipient of the products and services
Comments | Echo the Patient resource received in the request
Control | 1..1
Type | Reference(RTPBC Patient, Patient)
Is Modifier | false
Must Support | true
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Label | Response Patient Information
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ClaimResponse.created
Definition | The date this resource was created.
Short | Response creation date
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ClaimResponse.insurer
Definition | The party responsible for authorization, adjudication and reimbursement.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ClaimResponse.insurer.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. ClaimResponse.insurer.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ClaimResponse.insurer.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | Payer IDThe value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Payer ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ClaimResponse.request
Definition | The RTPBC Request ID contained in the associated request Original request resource reference.
Short | Submitter's RTPBC Request IDId of resource triggering adjudication
Control | 10..1
Type | Reference(Claim)
Is Modifier | false
Must Support | true
Summary | true
Label | Submitter's RTPBC Request ID
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ClaimResponse.request.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. ClaimResponse.request.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. ClaimResponse.request.identifier.value
Definition | The RTPBC Request ID contained in the associated request The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | RTPBC Request IDThe value that is unique
Comments | Populate with the Claim.identifier.value from the associated request If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | RTPBC Request ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ClaimResponse.outcome
Definition | The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'. Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse The outcome of the claim, predetermination, or preauthorization processing.
Short | Processing Outcomequeued | complete | error | partial
Comments | If the outcome = 'error', the .error composite must be populated. The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Label | Processing Outcome
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. ClaimResponse.disposition
Definition | Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes. A human readable description of the status of the adjudication.
Short | Completed NoteDisposition Message
Comments | The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message. Provided for user display.
Label | Completed Note
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. ClaimResponse.item
Definition | Composite containing cost and coverage for the requested product and pharmacy. A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Short | Requested Product and PharmacyAdjudication for claim line items
Comments | SHALL be populated when the .outcome = 'complete'.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The adjudication for items provided on the claim.
Label | Requested Product and Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. ClaimResponse.item.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
56. ClaimResponse.item.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
58. ClaimResponse.item.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
60. ClaimResponse.item.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
62. ClaimResponse.item.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. ClaimResponse.item.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. ClaimResponse.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
68. ClaimResponse.item.itemSequence
Definition | Indicates that the information in this .item composite relates to the requested product and pharmacy. A number to uniquely reference the claim item entries.
Short | Claim item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. ClaimResponse.item.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination. The numbers associated with notes below which apply to the adjudication of this item.
Short | Determination Note NumberApplicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. ClaimResponse.item.adjudication
Definition | Patient cost and coverage details for the requested product and pharmacy. If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Short | Requested Product and Pharmacy DeterminationAdjudication details
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Label | Requested Product and Pharmacy Determination
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. ClaimResponse.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
76. ClaimResponse.item.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost. A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
Short | Patient Pay ComponentType of adjudication information
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see RTPBC Patient Pay Type Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories The adjudication codes.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier. Needed to enable understanding of the context of the other information in the adjudication.
Label | Patient Pay Component
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. ClaimResponse.item.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category). Monetary amount associated with the category.
Short | Patient Pay Component AmountMonetary amount
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 10..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Label | Patient Pay Component Amount
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. ClaimResponse.item.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency. Numerical value (with implicit precision).
Short | Patient Pay Amount ValueNumerical value (with implicit precision)
Comments | Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 10..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The amount of the currency. The value includes an implicit precision in the presentation of the value.
Label | Patient Pay Amount Value
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. ClaimResponse.item.adjudication.amount.currency
Definition | ISO 4217 Currency Code.
Short | Patient Pay Amount CurrencyISO 4217 Currency Code
Control | 10..1
Binding | The codes SHALL be taken from Currencies http://hl7.org/fhir/ValueSet/currencies|4.0.1 (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies A code indicating the currency, taken from ISO 4217.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | A code indicating the currency, taken from ISO 4217.
Label | Patient Pay Amount Currency
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. ClaimResponse.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. ClaimResponse.addItem.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
88. ClaimResponse.addItem.extension:isAlternative
Slice Name | isAlternative
Definition | This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service
Short | Is Alternative (Extension)
Comments | Set to true in all real-time pharmacy benefit check response .addItems.
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(RTPBC isAlternative Extension) (Extension Type: boolean)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
90. ClaimResponse.addItem.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. ClaimResponse.addItem.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. ClaimResponse.addItem.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
96. ClaimResponse.addItem.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
98. ClaimResponse.addItem.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
100. ClaimResponse.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
102. ClaimResponse.addItem.itemSequence
Definition | Indicates that the information in this .item composite is an alternative to the requested product and pharmacy. Claim items which this service line is intended to replace.
Short | Associated request Item SequenceItem sequence number
Comments | Because a maximum of one product is submitted per request, this value is always '1'.
Control | 10..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides references to the claim items.
Label | Associated request Item Sequence
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. ClaimResponse.addItem.provider
Definition | Reference to an Organization resource representing the priced pharmacy The providers who are authorized for the services rendered to the patient.
Short | Priced PharmacyAuthorized providers
Control | 0..*
Type | Reference(RTPBC Pharmacy Organization, Practitioner, PractitionerRole, Organization)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Label | Priced Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. ClaimResponse.addItem.provider.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Reference to Priced PharmacyLiteral reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 10..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Reference to Priced Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. ClaimResponse.addItem.productOrService
Definition | A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form) When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | ProductBilling, service, product, or drug code
Comments | The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see RTPBC Prescribable Product Code Value Set http://hl7.org/fhir/ValueSet/service-uscls|4.0.1 (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code` ) RTPBC prescribable product codes (NDC11 and RxNorm) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Necessary to state what was provided or done.
Label | Product
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. ClaimResponse.addItem.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 10..*
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. ClaimResponse.addItem.productOrService.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 10..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. ClaimResponse.addItem.productOrService.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Symbol in syntax defined by the system
Control | 10..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ClaimResponse.addItem.productOrService.coding.display
Definition | The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired. A representation of the meaning of the code in the system, following the rules of the system.
Short | Product DescriptionRepresentation defined by the system
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Label | Product Description
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. ClaimResponse.addItem.quantity
Definition | The number of repetitions of a service or product.
Short | Priced QuantityCount of products or services
Control | 10..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Label | Priced Quantity
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. ClaimResponse.addItem.quantity.value
Definition | The prescribed quantity in terms of the applicable billing unit of measure. The value of the measured amount. The value includes an implicit precision in the presentation of the value.
Short | Quantity in Billing UnitsNumerical value (with implicit precision)
Comments | The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 10..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Precision is handled implicitly in almost all cases of measurement.
Label | Quantity in Billing Units
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. ClaimResponse.addItem.quantity.comparator
Definition | Not allowed to be used in this context How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.
Short | < | <= | >= | > - how to understand the value
Control | 0..01
Binding | The codes SHALL be taken from QuantityComparator http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1 (required to `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` ) How the Quantity should be understood and represented.
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.
Meaning if Missing | If there is no comparator, then there is no modification of the value
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. ClaimResponse.addItem.quantity.unit
Definition | Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each) A human-readable form of the unit.
Short | Billing unit of measureUnit representation
Control | 10..1
Binding | Unless not suitable, these codes SHALL be taken from For codes, see RTPBC Billing Unit Value Set (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit` ) Billing quantity unit of measure
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.
Label | Billing unit of measure
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. ClaimResponse.addItem.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination. The numbers associated with notes below which apply to the adjudication of this item.
Short | Determination Note NumberApplicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. ClaimResponse.addItem.adjudication
Definition | Patient cost and coverage details for an alternative product and pharmacy combination. The adjudication results.
Short | Alternative Product and Pharmacy DeterminationAdded items adjudication
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Label | Alternative Product and Pharmacy Determination
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. ClaimResponse.addItem.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
132. ClaimResponse.addItem.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost. A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
Short | Patient Pay ComponentType of adjudication information
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | The codes SHALL be taken from For example codes, see RTPBC Patient Pay Type Value Set http://hl7.org/fhir/ValueSet/adjudication|4.0.1 (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories The adjudication codes.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier. Needed to enable understanding of the context of the other information in the adjudication.
Label | Patient Pay Component
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
134. ClaimResponse.addItem.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category). Monetary amount associated with the category.
Short | Patient Pay Component AmountMonetary amount
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 10..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Label | Patient Pay Component Amount
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. ClaimResponse.addItem.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency. Numerical value (with implicit precision).
Short | Patient Pay Amount ValueNumerical value (with implicit precision)
Comments | Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 10..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The amount of the currency. The value includes an implicit precision in the presentation of the value.
Label | Patient Pay Amount Value
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. ClaimResponse.addItem.adjudication.amount.currency
Definition | ISO 4217 Currency Code.
Short | Patient Pay Amount CurrencyISO 4217 Currency Code
Control | 10..1
Binding | The codes SHALL be taken from Currencies http://hl7.org/fhir/ValueSet/currencies|4.0.1 (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies A code indicating the currency, taken from ISO 4217.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | A code indicating the currency, taken from ISO 4217.
Label | Patient Pay Amount Currency
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. ClaimResponse.processNote
Definition | Additional coverage determination information for a product / pharmacy combination. A note that describes or explains adjudication results in a human readable form.
Short | Determination NoteNote concerning adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Provides the insurer specific textual explanations associated with the processing.
Label | Determination Note
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. ClaimResponse.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
144. ClaimResponse.processNote.number
Definition | A number to uniquely identify a note entry.
Short | Determination Note NumberNote instance identifier
Comments | Links to the .noteNumber elements in .item and .addItem
Control | 10..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Necessary to provide a mechanism to link from adjudications.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. ClaimResponse.processNote.text
Definition | The explanation or description associated with the processing.
Short | Determination Note TextNote explanatory text
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Required to provide human readable explanation.
Label | Determination Note Text
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. ClaimResponse.error
Definition | Errors encountered during the processing of the adjudication.
Short | Error InformationProcessing errors
Comments | Must be populated when .outcome = 'error' If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Need to communicate processing issues to the requestor.
Label | Error Information
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. ClaimResponse.error.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
152. ClaimResponse.error.code
Definition | A code identifying the reason that processing could not be completed. An error code, from a specified code system, which details why the claim could not be adjudicated.
Short | Reject ReasonError code detailing processing issues
Control | 1..1
Binding | The codes SHOULD be taken from For example codes, see RTPBC Error Code Value Set http://hl7.org/fhir/ValueSet/adjudication-error|4.0.1 (preferred to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code` ) RTPBC Error Codes The adjudication error codes.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required to convey processing errors.
Label | Reject Reason
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
154. ClaimResponse.error.code.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 10..*
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
156. ClaimResponse.error.code.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 10..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. ClaimResponse.error.code.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Reject CodeSymbol in syntax defined by the system
Control | 10..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Label | Reject Code
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
160. ClaimResponse.error.code.coding.display
Definition | A representation of the meaning of the code in the system, following the rules of the system.
Short | Representation defined by the system
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. ClaimResponse.error.code.text
Definition | Clarification of the reject cause. A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Reject MessagePlain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Label | Reject Message
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
2. ClaimResponse.id
Definition | Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM
Short | Unique ClaimResponse Resource Identifier
Must Support | true
Label | Unique ClaimResponse Resource Identifier
4. ClaimResponse.identifier
Short | RTPBC Response Identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
Must Support | true
Label | RTPBC Response Identifier
6. ClaimResponse.identifier.value
Definition | An identifier for each RTPBC response that is assigned by and unique to the reponder
Short | Unique RTPBC response ID
Control | 1..?
Must Support | true
Label | Unique RTPBC response ID
8. ClaimResponse.status
Definition | The status of this response (active)
Short | Response status
Comments | Value is always 'active'
Must Support | true
Label | Response status
Fixed Value | `active`
10. ClaimResponse.type
Definition | The type of service for which pricing and coverage predetermination is being requested
Short | Requested Service Type
Comments | Value is always 'pharmacy'
Must Support | true
Label | Requested Service Type
12. ClaimResponse.type.coding
Control | 1..1
Must Support | true
14. ClaimResponse.type.coding.system
Control | 1..?
Must Support | true
Fixed Value | `http://terminology.hl7.org/CodeSystem/claim-type`
16. ClaimResponse.type.coding.code
Control | 1..?
Must Support | true
Fixed Value | `pharmacy`
18. ClaimResponse.type.coding.display
Control | 1..?
Must Support | true
Fixed Value | `Pharmacy`
20. ClaimResponse.use
Definition | The mode of processing being performed by the payer/PBM
Short | Processing Mode
Comments | Value is always 'predetermination'
Must Support | true
Label | Processing Mode
Fixed Value | `predetermination`
22. ClaimResponse.patient
Definition | Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process
Short | Response Patient Information
Comments | Echo the Patient resource received in the request
Type | Reference(RTPBC Patient)
Must Support | true
Label | Response Patient Information
24. ClaimResponse.insurer
Must Support | true
26. ClaimResponse.insurer.identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
Must Support | true
28. ClaimResponse.insurer.identifier.value
Short | Payer ID
Control | 1..?
Must Support | true
Label | Payer ID
30. ClaimResponse.request
Definition | The RTPBC Request ID contained in the associated request
Short | Submitter's RTPBC Request ID
Control | 1..?
Must Support | true
Label | Submitter's RTPBC Request ID
32. ClaimResponse.request.identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
Must Support | true
34. ClaimResponse.request.identifier.value
Definition | The RTPBC Request ID contained in the associated request
Short | RTPBC Request ID
Comments | Populate with the Claim.identifier.value from the associated request
Control | 1..?
Must Support | true
Label | RTPBC Request ID
36. ClaimResponse.outcome
Definition | The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'. Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse
Short | Processing Outcome
Comments | If the outcome = 'error', the .error composite must be populated.
Must Support | true
Label | Processing Outcome
38. ClaimResponse.disposition
Definition | Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.
Short | Completed Note
Comments | The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.
Must Support | true
Requirements | Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.
Label | Completed Note
40. ClaimResponse.item
Definition | Composite containing cost and coverage for the requested product and pharmacy.
Short | Requested Product and Pharmacy
Comments | SHALL be populated when the .outcome = 'complete'.
Must Support | true
Label | Requested Product and Pharmacy
42. ClaimResponse.item.extension
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
44. ClaimResponse.item.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..*
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Must Support | true
46. ClaimResponse.item.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..*
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Must Support | true
48. ClaimResponse.item.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..*
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Must Support | true
50. ClaimResponse.item.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..*
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Must Support | true
52. ClaimResponse.item.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..*
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Must Support | true
54. ClaimResponse.item.itemSequence
Definition | Indicates that the information in this .item composite relates to the requested product and pharmacy.
Must Support | true
56. ClaimResponse.item.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.
Short | Determination Note Number
Must Support | true
Label | Determination Note Number
58. ClaimResponse.item.adjudication
Definition | Patient cost and coverage details for the requested product and pharmacy.
Short | Requested Product and Pharmacy Determination
Must Support | true
Label | Requested Product and Pharmacy Determination
60. ClaimResponse.item.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost.
Short | Patient Pay Component
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request
Binding | The codes SHALL be taken from RTPBC Patient Pay Type Value Set (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories
Must Support | true
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.
Label | Patient Pay Component
62. ClaimResponse.item.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category).
Short | Patient Pay Component Amount
Control | 1..?
Must Support | true
Label | Patient Pay Component Amount
64. ClaimResponse.item.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency.
Short | Patient Pay Amount Value
Control | 1..?
Must Support | true
Label | Patient Pay Amount Value
66. ClaimResponse.item.adjudication.amount.currency
Short | Patient Pay Amount Currency
Control | 1..?
Binding | The codes SHALL be taken from Currencies (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies
Must Support | true
Label | Patient Pay Amount Currency
68. ClaimResponse.addItem
Must Support | true
70. ClaimResponse.addItem.extension
Control | 1..?
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
72. ClaimResponse.addItem.extension:isAlternative
Slice Name | isAlternative
Definition | This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service
Short | Is Alternative (Extension)
Comments | Set to true in all real-time pharmacy benefit check response .addItems.
Control | 1..1
Type | Extension(RTPBC isAlternative Extension) (Extension Type: boolean)
Must Support | true
74. ClaimResponse.addItem.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..*
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Must Support | true
76. ClaimResponse.addItem.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..*
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Must Support | true
78. ClaimResponse.addItem.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..*
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Must Support | true
80. ClaimResponse.addItem.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..*
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Must Support | true
82. ClaimResponse.addItem.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..*
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Must Support | true
84. ClaimResponse.addItem.itemSequence
Definition | Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.
Short | Associated request Item Sequence
Comments | Because a maximum of one product is submitted per request, this value is always '1'.
Control | 1..?
Must Support | true
Label | Associated request Item Sequence
86. ClaimResponse.addItem.provider
Definition | Reference to an Organization resource representing the priced pharmacy
Short | Priced Pharmacy
Type | Reference(RTPBC Pharmacy Organization)
Must Support | true
Label | Priced Pharmacy
88. ClaimResponse.addItem.provider.reference
Short | Reference to Priced Pharmacy
Control | 1..?
Must Support | true
Label | Reference to Priced Pharmacy
90. ClaimResponse.addItem.productOrService
Definition | A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)
Short | Product
Comments | The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes
Binding | Unless not suitable, these codes SHALL be taken from RTPBC Prescribable Product Code Value Set (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code` ) RTPBC prescribable product codes (NDC11 and RxNorm)
Must Support | true
Label | Product
92. ClaimResponse.addItem.productOrService.coding
Control | 1..?
Must Support | true
94. ClaimResponse.addItem.productOrService.coding.system
Control | 1..?
Must Support | true
96. ClaimResponse.addItem.productOrService.coding.code
Control | 1..?
Must Support | true
98. ClaimResponse.addItem.productOrService.coding.display
Definition | The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired.
Short | Product Description
Control | 1..?
Must Support | true
Label | Product Description
100. ClaimResponse.addItem.quantity
Short | Priced Quantity
Control | 1..?
Must Support | true
Label | Priced Quantity
102. ClaimResponse.addItem.quantity.value
Definition | The prescribed quantity in terms of the applicable billing unit of measure.
Short | Quantity in Billing Units
Control | 1..?
Must Support | true
Label | Quantity in Billing Units
104. ClaimResponse.addItem.quantity.unit
Definition | Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)
Short | Billing unit of measure
Control | 1..?
Binding | Unless not suitable, these codes SHALL be taken from RTPBC Billing Unit Value Set (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit` ) Billing quantity unit of measure
Must Support | true
Label | Billing unit of measure
106. ClaimResponse.addItem.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.
Short | Determination Note Number
Must Support | true
Label | Determination Note Number
108. ClaimResponse.addItem.adjudication
Definition | Patient cost and coverage details for an alternative product and pharmacy combination.
Short | Alternative Product and Pharmacy Determination
Type | BackboneElement
Must Support | true
Label | Alternative Product and Pharmacy Determination
110. ClaimResponse.addItem.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost.
Short | Patient Pay Component
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product
Binding | The codes SHALL be taken from RTPBC Patient Pay Type Value Set (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories
Must Support | true
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.
Label | Patient Pay Component
112. ClaimResponse.addItem.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category).
Short | Patient Pay Component Amount
Control | 1..?
Must Support | true
Label | Patient Pay Component Amount
114. ClaimResponse.addItem.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency.
Short | Patient Pay Amount Value
Control | 1..?
Must Support | true
Label | Patient Pay Amount Value
116. ClaimResponse.addItem.adjudication.amount.currency
Short | Patient Pay Amount Currency
Control | 1..?
Binding | The codes SHALL be taken from Currencies (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies
Must Support | true
Label | Patient Pay Amount Currency
118. ClaimResponse.processNote
Definition | Additional coverage determination information for a product / pharmacy combination.
Short | Determination Note
Must Support | true
Label | Determination Note
120. ClaimResponse.processNote.number
Short | Determination Note Number
Comments | Links to the .noteNumber elements in .item and .addItem
Control | 1..?
Must Support | true
Label | Determination Note Number
122. ClaimResponse.processNote.text
Short | Determination Note Text
Must Support | true
Label | Determination Note Text
124. ClaimResponse.error
Short | Error Information
Comments | Must be populated when .outcome = 'error'
Must Support | true
Label | Error Information
126. ClaimResponse.error.code
Definition | A code identifying the reason that processing could not be completed.
Short | Reject Reason
Binding | The codes SHOULD be taken from RTPBC Error Code Value Set (preferred to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code` ) RTPBC Error Codes
Must Support | true
Label | Reject Reason
128. ClaimResponse.error.code.coding
Control | 1..?
Must Support | true
130. ClaimResponse.error.code.coding.system
Control | 1..?
Must Support | true
132. ClaimResponse.error.code.coding.code
Short | Reject Code
Control | 1..?
Must Support | true
Label | Reject Code
134. ClaimResponse.error.code.coding.display
Control | 1..?
Must Support | true
136. ClaimResponse.error.code.text
Definition | Clarification of the reject cause.
Short | Reject Message
Must Support | true
Label | Reject Message

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
Definition | This resource provides the adjudication details from the processing of a Claim resource.
Short | Response to a claim predetermination or preauthorization
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Remittance Advice
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) 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 (`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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`)
2. ClaimResponse.id
Definition | Unique ClaimResponse Resource Identifier assigned by the responding payer/PBM
Short | Unique ClaimResponse Resource Identifier
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Must Support | true
Summary | true
Label | Unique ClaimResponse Resource Identifier
4. ClaimResponse.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. ClaimResponse.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
8. ClaimResponse.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
10. ClaimResponse.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. ClaimResponse.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
14. ClaimResponse.extension
Definition | May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
16. ClaimResponse.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
18. ClaimResponse.identifier
Definition | A unique identifier assigned to this claim response.
Short | RTPBC Response Identifier
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
Is Modifier | false
Must Support | true
Summary | false
Requirements | Allows claim responses to be distinguished and referenced.
Label | RTPBC Response Identifier
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
20. ClaimResponse.identifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
22. ClaimResponse.identifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.identifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
24. ClaimResponse.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
26. ClaimResponse.identifier.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
28. ClaimResponse.identifier.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. ClaimResponse.identifier.value
Definition | An identifier for each RTPBC response that is assigned by and unique to the reponder
Short | Unique RTPBC response ID
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Unique RTPBC response ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. ClaimResponse.identifier.period
Definition | Time period during which identifier is/was valid for use.
Short | Time period when id is/was valid for use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. ClaimResponse.identifier.assigner
Definition | Organization that issued/manages the identifier.
Short | Organization that issued id (may be just text)
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. ClaimResponse.status
Definition | The status of this response (active)
Short | Response status
Comments | Value is always 'active'
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Label | Response status
Fixed Value | `active`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. ClaimResponse.type
Definition | The type of service for which pricing and coverage predetermination is being requested
Short | Requested Service Type
Comments | Value is always 'pharmacy'
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from ClaimTypeCodes (extensible to `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` ) The type or discipline-style of the claim.
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | true
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Label | Requested Service Type
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. ClaimResponse.type.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
42. ClaimResponse.type.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.type.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
44. ClaimResponse.type.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 1..1
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
46. ClaimResponse.type.coding.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
48. ClaimResponse.type.coding.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.type.coding.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
50. ClaimResponse.type.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Fixed Value | `http://terminology.hl7.org/CodeSystem/claim-type`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
52. ClaimResponse.type.coding.version
Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Short | Version of the system - if relevant
Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. ClaimResponse.type.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Symbol in syntax defined by the system
Control | 1..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Fixed Value | `pharmacy`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
56. ClaimResponse.type.coding.display
Definition | A representation of the meaning of the code in the system, following the rules of the system.
Short | Representation defined by the system
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Fixed Value | `Pharmacy`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
58. ClaimResponse.type.coding.userSelected
Definition | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Short | If this coding was chosen directly by the user
Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. ClaimResponse.type.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. ClaimResponse.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 0..1
Binding | For example codes, see ExampleClaimSubTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` ) A more granular claim typecode.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. ClaimResponse.use
Definition | The mode of processing being performed by the payer/PBM
Short | Processing Mode
Comments | Value is always 'predetermination'
Control | 1..1
Binding | The codes SHALL be taken from Use (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Claim, preauthorization, predetermination.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Label | Processing Mode
Fixed Value | `predetermination`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
66. ClaimResponse.patient
Definition | Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process
Short | Response Patient Information
Comments | Echo the Patient resource received in the request
Control | 1..1
Type | Reference(RTPBC Patient)
Is Modifier | false
Must Support | true
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Label | Response Patient Information
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
68. ClaimResponse.created
Definition | The date this resource was created.
Short | Response creation date
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
70. ClaimResponse.insurer
Definition | The party responsible for authorization, adjudication and reimbursement.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(Organization)
Is Modifier | false
Must Support | true
Summary | true
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
72. ClaimResponse.insurer.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
74. ClaimResponse.insurer.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.insurer.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
76. ClaimResponse.insurer.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Literal reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 0..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. ClaimResponse.insurer.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. ClaimResponse.insurer.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
82. ClaimResponse.insurer.identifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
84. ClaimResponse.insurer.identifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.insurer.identifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
86. ClaimResponse.insurer.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
88. ClaimResponse.insurer.identifier.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
90. ClaimResponse.insurer.identifier.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
92. ClaimResponse.insurer.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | Payer ID
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Payer ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
94. ClaimResponse.insurer.identifier.period
Definition | Time period during which identifier is/was valid for use.
Short | Time period when id is/was valid for use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
96. ClaimResponse.insurer.identifier.assigner
Definition | Organization that issued/manages the identifier.
Short | Organization that issued id (may be just text)
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. ClaimResponse.insurer.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
100. ClaimResponse.requestor
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Short | Party responsible for the claim
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Control | 0..1
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
102. ClaimResponse.request
Definition | The RTPBC Request ID contained in the associated request
Short | Submitter's RTPBC Request ID
Control | 1..1
Type | Reference(Claim)
Is Modifier | false
Must Support | true
Summary | true
Label | Submitter's RTPBC Request ID
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
104. ClaimResponse.request.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
106. ClaimResponse.request.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.request.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
108. ClaimResponse.request.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Literal reference, Relative, internal or absolute URL
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 0..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
110. ClaimResponse.request.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
112. ClaimResponse.request.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..1
Type | Identifier
Is Modifier | false
Must Support | true
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
114. ClaimResponse.request.identifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
116. ClaimResponse.request.identifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.request.identifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
118. ClaimResponse.request.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
120. ClaimResponse.request.identifier.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to `http://hl7.org/fhir/ValueSet/identifier-type|4.0.1` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
122. ClaimResponse.request.identifier.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 0..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
124. ClaimResponse.request.identifier.value
Definition | The RTPBC Request ID contained in the associated request
Short | RTPBC Request ID
Comments | Populate with the Claim.identifier.value from the associated request
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | RTPBC Request ID
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. ClaimResponse.request.identifier.period
Definition | Time period during which identifier is/was valid for use.
Short | Time period when id is/was valid for use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. ClaimResponse.request.identifier.assigner
Definition | Organization that issued/manages the identifier.
Short | Organization that issued id (may be just text)
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
130. ClaimResponse.request.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
132. ClaimResponse.outcome
Definition | The outcome of processing. Either 'complete' (finished without errors) or 'error' (processing could not complete). The outcome is 'processed' if processing completes with a coverage determination, including when it is determined that the requested product is not covered. Otherwise, the outcome = 'error'. Note: If a system or communication error occurs, an OperationOutcome is returned instead of a ClaimResponse
Short | Processing Outcome
Comments | If the outcome = 'error', the .error composite must be populated.
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Label | Processing Outcome
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
134. ClaimResponse.disposition
Definition | Note providing clarifying information and/or support contact information. Available for both 'completed' and 'error' outcomes.
Short | Completed Note
Comments | The responding payer/PBM determines when and how to populate.Recommended that a patient help desk phone number be included.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Corresponds to the Help Desk Support elements in the NCPDP RTPBC response message.
Label | Completed Note
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
136. ClaimResponse.preAuthRef
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication.
Short | Preauthorization reference
Comments | This value is only present on preauthorization adjudications.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
138. ClaimResponse.preAuthPeriod
Definition | The time frame during which this authorization is effective.
Short | Preauthorization reference effective period
Control | 0..1
Type | Period
Is Modifier | false
Summary | false
Requirements | To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
140. ClaimResponse.payeeType
Definition | Type of Party to be reimbursed: subscriber, provider, other.
Short | Party to be paid any benefits payable
Control | 0..1
Binding | For example codes, see Claim Payee Type Codes (example to `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
142. ClaimResponse.item
Definition | Composite containing cost and coverage for the requested product and pharmacy.
Short | Requested Product and Pharmacy
Comments | SHALL be populated when the .outcome = 'complete'.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The adjudication for items provided on the claim.
Label | Requested Product and Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
144. ClaimResponse.item.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
146. ClaimResponse.item.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
148. ClaimResponse.item.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
150. ClaimResponse.item.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
152. ClaimResponse.item.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
154. ClaimResponse.item.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
156. ClaimResponse.item.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
158. ClaimResponse.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
160. ClaimResponse.item.itemSequence
Definition | Indicates that the information in this .item composite relates to the requested product and pharmacy.
Short | Claim item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. ClaimResponse.item.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.
Short | Determination Note Number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
164. ClaimResponse.item.adjudication
Definition | Patient cost and coverage details for the requested product and pharmacy.
Short | Requested Product and Pharmacy Determination
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Label | Requested Product and Pharmacy Determination
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
166. ClaimResponse.item.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
168. ClaimResponse.item.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
170. ClaimResponse.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
172. ClaimResponse.item.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost.
Short | Patient Pay Component
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request
Control | 1..1
Binding | The codes SHALL be taken from RTPBC Patient Pay Type Value Set (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.
Label | Patient Pay Component
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
174. ClaimResponse.item.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) The adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
176. ClaimResponse.item.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category).
Short | Patient Pay Component Amount
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 1..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Label | Patient Pay Component Amount
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
178. ClaimResponse.item.adjudication.amount.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
180. ClaimResponse.item.adjudication.amount.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.item.adjudication.amount.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
182. ClaimResponse.item.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency.
Short | Patient Pay Amount Value
Comments | Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 1..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The amount of the currency. The value includes an implicit precision in the presentation of the value.
Label | Patient Pay Amount Value
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
184. ClaimResponse.item.adjudication.amount.currency
Definition | ISO 4217 Currency Code.
Short | Patient Pay Amount Currency
Control | 1..1
Binding | The codes SHALL be taken from Currencies (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | A code indicating the currency, taken from ISO 4217.
Label | Patient Pay Amount Currency
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
186. ClaimResponse.item.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monetary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
188. ClaimResponse.item.detail
Definition | A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Adjudication for claim details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for details provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
190. ClaimResponse.item.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
192. ClaimResponse.item.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
194. ClaimResponse.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
196. ClaimResponse.item.detail.detailSequence
Definition | A number to uniquely reference the claim detail entry.
Short | Claim detail instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
198. ClaimResponse.item.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
200. ClaimResponse.item.detail.adjudication
Definition | The adjudication results.
Short | Detail level adjudication details
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
202. ClaimResponse.item.detail.subDetail
Definition | A sub-detail adjudication of a simple product or service.
Short | Adjudication for claim sub-details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for sub-details provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
204. ClaimResponse.item.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
206. ClaimResponse.item.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
208. ClaimResponse.item.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
210. ClaimResponse.item.detail.subDetail.subDetailSequence
Definition | A number to uniquely reference the claim sub-detail entry.
Short | Claim sub-detail instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
212. ClaimResponse.item.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
214. ClaimResponse.item.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Subdetail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
216. ClaimResponse.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
218. ClaimResponse.addItem.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
220. ClaimResponse.addItem.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
222. ClaimResponse.addItem.extension:isAlternative
Slice Name | isAlternative
Definition | This extension indicates that this added line item is to be interpreted as one of possibly multiple alternatives to the requested product or service. When isAlternative is true, the added line item is to be considered independently from any other added line items associated with the requested product or service
Short | Is Alternative (Extension)
Comments | Set to true in all real-time pharmacy benefit check response .addItems.
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(RTPBC isAlternative Extension) (Extension Type: boolean)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
224. ClaimResponse.addItem.extension:benefitRestriction
Slice Name | benefitRestriction
Definition | This extension conveys benefit restrictions that may apply to a prescription product and pharmacy combination.
Short | Benefit Restriction (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC benefitRestriction Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
226. ClaimResponse.addItem.extension:formularyStatus
Slice Name | formularyStatus
Definition | This extension conveys the formulary status that applies to the product.
Short | Formulary Status (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC formularyStatus Extension) (Extension Type: Coding)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
228. ClaimResponse.addItem.extension:preferenceLevel
Slice Name | preferenceLevel
Definition | This extension conveys the preference level that applies to the product.
Short | Preference Level (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC preferenceLevel Extension) (Extension Type: positiveInt)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
230. ClaimResponse.addItem.extension:nextAvailableFillDate
Slice Name | nextAvailableFillDate
Definition | This extension conveys the date on which a patient prescription will have passed the insurer's minimum consumption requirements and may be considered for dispensing.
Short | Next Available Fill Date (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC nextAvailableFillDate Extension) (Extension Type: date)
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
232. ClaimResponse.addItem.extension:relatedCoverage
Slice Name | relatedCoverage
Definition | This extension conveys the coverage associated with an RTPBC Response item or addItem.
Short | Related Coverage (Extension)
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(RTPBC relatedCoverage Extension) (Extension Type: Reference(RTPBC Coverage, RTPBC Coverage - Non-PHI))
Is Modifier | false
Must Support | true
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
234. ClaimResponse.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
236. ClaimResponse.addItem.itemSequence
Definition | Indicates that the information in this .item composite is an alternative to the requested product and pharmacy.
Short | Associated request Item Sequence
Comments | Because a maximum of one product is submitted per request, this value is always '1'.
Control | 1..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides references to the claim items.
Label | Associated request Item Sequence
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
238. ClaimResponse.addItem.detailSequence
Definition | The sequence number of the details within the claim item which this line is intended to replace.
Short | Detail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
240. ClaimResponse.addItem.subdetailSequence
Definition | The sequence number of the sub-details within the details within the claim item which this line is intended to replace.
Short | Subdetail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
242. ClaimResponse.addItem.provider
Definition | Reference to an Organization resource representing the priced pharmacy
Short | Priced Pharmacy
Control | 0..*
Type | Reference(RTPBC Pharmacy Organization)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Label | Priced Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
244. ClaimResponse.addItem.provider.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
246. ClaimResponse.addItem.provider.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.provider.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
248. ClaimResponse.addItem.provider.reference
Definition | A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
Short | Reference to Priced Pharmacy
Comments | Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
Control | 1..1 This element is affected by the following invariants: ref-1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Label | Reference to Priced Pharmacy
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
250. ClaimResponse.addItem.provider.type
Definition | The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
Short | Type the reference refers to (e.g. "Patient")
Comments | This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from ResourceType (extensible to `http://hl7.org/fhir/ValueSet/resource-types|4.0.1` ) Aa resource (or, for logical models, the URI of the logical model).
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
252. ClaimResponse.addItem.provider.identifier
Definition | An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
Short | Logical reference, when literal reference is not known
Comments | When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
254. ClaimResponse.addItem.provider.display
Definition | Plain text narrative that identifies the resource in addition to the resource reference.
Short | Text alternative for the resource
Comments | This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
256. ClaimResponse.addItem.productOrService
Definition | A product identifier for the medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)
Short | Product
Comments | The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from RTPBC Prescribable Product Code Value Set (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code` ) RTPBC prescribable product codes (NDC11 and RxNorm)
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Necessary to state what was provided or done.
Label | Product
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
258. ClaimResponse.addItem.productOrService.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
260. ClaimResponse.addItem.productOrService.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.productOrService.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
262. ClaimResponse.addItem.productOrService.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 1..*
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
264. ClaimResponse.addItem.productOrService.coding.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
266. ClaimResponse.addItem.productOrService.coding.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.productOrService.coding.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
268. ClaimResponse.addItem.productOrService.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
270. ClaimResponse.addItem.productOrService.coding.version
Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Short | Version of the system - if relevant
Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
272. ClaimResponse.addItem.productOrService.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Symbol in syntax defined by the system
Control | 1..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
274. ClaimResponse.addItem.productOrService.coding.display
Definition | The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired.
Short | Product Description
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Label | Product Description
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
276. ClaimResponse.addItem.productOrService.coding.userSelected
Definition | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Short | If this coding was chosen directly by the user
Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
278. ClaimResponse.addItem.productOrService.text
Definition | A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Short | Plain text representation of the concept
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
280. ClaimResponse.addItem.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
282. ClaimResponse.addItem.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
284. ClaimResponse.addItem.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Short | Date or dates of service or product delivery
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
286. ClaimResponse.addItem.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place|4.0.1` ) Place of service: pharmacy, school, prison, etc.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
288. ClaimResponse.addItem.quantity
Definition | The number of repetitions of a service or product.
Short | Priced Quantity
Control | 1..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Label | Priced Quantity
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
290. ClaimResponse.addItem.quantity.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
292. ClaimResponse.addItem.quantity.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.quantity.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
294. ClaimResponse.addItem.quantity.value
Definition | The prescribed quantity in terms of the applicable billing unit of measure.
Short | Quantity in Billing Units
Comments | The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 1..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Precision is handled implicitly in almost all cases of measurement.
Label | Quantity in Billing Units
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
296. ClaimResponse.addItem.quantity.comparator
Definition | Not allowed to be used in this context
Short | < | <= | >= | > - how to understand the value
Control | 0..0
Binding | The codes SHALL be taken from QuantityComparator (required to `http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1` ) How the Quantity should be understood and represented.
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.
Meaning if Missing | If there is no comparator, then there is no modification of the value
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
298. ClaimResponse.addItem.quantity.unit
Definition | Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)
Short | Billing unit of measure
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from RTPBC Billing Unit Value Set (extensible to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit` ) Billing quantity unit of measure
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.
Label | Billing unit of measure
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
300. ClaimResponse.addItem.quantity.system
Definition | The identification of the system that provides the coded form of the unit.
Short | System that defines coded unit form
Control | 0..1 This element is affected by the following invariants: qty-3
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to know the system that defines the coded form of the unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
302. ClaimResponse.addItem.quantity.code
Definition | A computer processable form of the unit in some unit representation system.
Short | Coded form of the unit
Comments | The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.
Control | 0..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
304. ClaimResponse.addItem.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
306. ClaimResponse.addItem.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
308. ClaimResponse.addItem.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
310. ClaimResponse.addItem.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical location
Comments | For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth|4.0.1` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
312. ClaimResponse.addItem.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface|4.0.1` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
314. ClaimResponse.addItem.noteNumber
Definition | Number referencing a Determination Note (.processNote) explaining the coverage status for this product + pharmacy combination.
Short | Determination Note Number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
316. ClaimResponse.addItem.adjudication
Definition | Patient cost and coverage details for an alternative product and pharmacy combination.
Short | Alternative Product and Pharmacy Determination
Control | 1..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Label | Alternative Product and Pharmacy Determination
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
318. ClaimResponse.addItem.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
320. ClaimResponse.addItem.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
322. ClaimResponse.addItem.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
324. ClaimResponse.addItem.adjudication.category
Definition | Identifies a component of the patient's financial responsibility for the product cost.
Short | Patient Pay Component
Comments | At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product
Control | 1..1
Binding | The codes SHALL be taken from RTPBC Patient Pay Type Value Set (required to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-patient-pay-type` ) RTPBC Patient Pay Categories
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Corresponds to NCPDP C95-KQ Patient Pay Component Qualifier.
Label | Patient Pay Component
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
326. ClaimResponse.addItem.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Explanation of adjudication outcome
Comments | For example may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | For example codes, see AdjudicationReasonCodes (example to `http://hl7.org/fhir/ValueSet/adjudication-reason|4.0.1` ) The adjudication reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
328. ClaimResponse.addItem.adjudication.amount
Definition | The amount associated with the Patient Pay Component (.adjudication.category).
Short | Patient Pay Component Amount
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 1..1
Type | Money
Is Modifier | false
Must Support | true
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Label | Patient Pay Component Amount
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
330. ClaimResponse.addItem.adjudication.amount.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
332. ClaimResponse.addItem.adjudication.amount.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.addItem.adjudication.amount.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
334. ClaimResponse.addItem.adjudication.amount.value
Definition | The patient pay component amount in terms of the specified currency.
Short | Patient Pay Amount Value
Comments | Monetary values have their own rules for handling precision (refer to standard accounting text books).
Control | 1..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The amount of the currency. The value includes an implicit precision in the presentation of the value.
Label | Patient Pay Amount Value
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
336. ClaimResponse.addItem.adjudication.amount.currency
Definition | ISO 4217 Currency Code.
Short | Patient Pay Amount Currency
Control | 1..1
Binding | The codes SHALL be taken from Currencies (required to `http://hl7.org/fhir/ValueSet/currencies` ) Currencies
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | A code indicating the currency, taken from ISO 4217.
Label | Patient Pay Amount Currency
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
338. ClaimResponse.addItem.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monetary value
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
340. ClaimResponse.addItem.detail
Definition | The second-tier service adjudications for payor added services.
Short | Insurer added line details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
342. ClaimResponse.addItem.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
344. ClaimResponse.addItem.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
346. ClaimResponse.addItem.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
348. ClaimResponse.addItem.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
350. ClaimResponse.addItem.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
352. ClaimResponse.addItem.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
354. ClaimResponse.addItem.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
356. ClaimResponse.addItem.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
358. ClaimResponse.addItem.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
360. ClaimResponse.addItem.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
362. ClaimResponse.addItem.detail.adjudication
Definition | The adjudication results.
Short | Added items detail adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
364. ClaimResponse.addItem.detail.subDetail
Definition | The third-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
366. ClaimResponse.addItem.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
368. ClaimResponse.addItem.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
370. ClaimResponse.addItem.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
372. ClaimResponse.addItem.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
374. ClaimResponse.addItem.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
376. ClaimResponse.addItem.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
378. ClaimResponse.addItem.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
380. ClaimResponse.addItem.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
382. ClaimResponse.addItem.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
384. ClaimResponse.addItem.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
386. ClaimResponse.addItem.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Added items detail adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
388. ClaimResponse.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Header-level adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
390. ClaimResponse.total
Definition | Categorized monetary totals for the adjudication.
Short | Adjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | To provide the requestor with financial totals by category for the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
392. ClaimResponse.total.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
394. ClaimResponse.total.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
396. ClaimResponse.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
398. ClaimResponse.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Short | Type of adjudication information
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | For example codes, see AdjudicationValueCodes (example to `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` ) The adjudication codes.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Needed to convey the type of total provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
400. ClaimResponse.total.amount
Definition | Monetary total amount associated with the category.
Short | Financial total for the category
Control | 1..1
Type | Money
Is Modifier | false
Summary | true
Requirements | Needed to convey the total monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
402. ClaimResponse.payment
Definition | Payment details for the adjudication of the claim.
Short | Payment Details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
404. ClaimResponse.payment.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
406. ClaimResponse.payment.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
408. ClaimResponse.payment.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
410. ClaimResponse.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Short | Partial or complete payment
Control | 1..1
Binding | For example codes, see ExamplePaymentTypeCodes (example to `http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1` ) The type (partial, complete) of the payment.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
412. ClaimResponse.payment.adjustment
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Short | Payment adjustment for non-claim issues
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | To advise the requestor of adjustments applied to the payment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
414. ClaimResponse.payment.adjustmentReason
Definition | Reason for the payment adjustment.
Short | Explanation for the adjustment
Control | 0..1
Binding | For example codes, see PaymentAdjustmentReasonCodes (example to `http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1` ) Payment Adjustment reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to clarify the monetary adjustment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
416. ClaimResponse.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Short | Expected date of payment
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To advise the payee when payment can be expected.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
418. ClaimResponse.payment.amount
Definition | Benefits payable less any payment adjustment.
Short | Payable amount after adjustment
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Needed to provide the actual payment amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
420. ClaimResponse.payment.identifier
Definition | Issuer's unique identifier for the payment instrument.
Short | Business identifier for the payment
Comments | For example: EFT number or check number.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Enable the receiver to reconcile when payment received.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
422. ClaimResponse.fundsReserve
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Short | Funds reserved status
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
424. ClaimResponse.formCode
Definition | A code for the form to be used for printing the content.
Short | Printed form identifier
Comments | May be needed to identify specific jurisdictional forms.
Control | 0..1
Binding | For example codes, see Form Codes (example to `http://hl7.org/fhir/ValueSet/forms|4.0.1` ) The forms codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to specify the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
426. ClaimResponse.form
Definition | The actual form, by reference or inclusion, for printing the content or an EOB.
Short | Printed reference or actual form
Comments | Needed to permit insurers to include the actual form.
Control | 0..1
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Needed to include the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
428. ClaimResponse.processNote
Definition | Additional coverage determination information for a product / pharmacy combination.
Short | Determination Note
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Provides the insurer specific textual explanations associated with the processing.
Label | Determination Note
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
430. ClaimResponse.processNote.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
432. ClaimResponse.processNote.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
434. ClaimResponse.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
436. ClaimResponse.processNote.number
Definition | A number to uniquely identify a note entry.
Short | Determination Note Number
Comments | Links to the .noteNumber elements in .item and .addItem
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Necessary to provide a mechanism to link from adjudications.
Label | Determination Note Number
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
438. ClaimResponse.processNote.type
Definition | The business purpose of the note text.
Short | display | print | printoper
Control | 0..1
Binding | The codes SHALL be taken from NoteType (required to `http://hl7.org/fhir/ValueSet/note-type|4.0.1` ) The presentation types of notes.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the expectation for when the text is used.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
440. ClaimResponse.processNote.text
Definition | The explanation or description associated with the processing.
Short | Determination Note Text
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | false
Requirements | Required to provide human readable explanation.
Label | Determination Note Text
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
442. ClaimResponse.processNote.language
Definition | A code to define the language used in the text of the note.
Short | Language of the text
Comments | Only required if the language is different from the resource language.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages|4.0.1` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Note text may vary from the resource defined language.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
444. ClaimResponse.communicationRequest
Definition | Request for additional supporting or authorizing information.
Short | Request for additional information
Comments | For example: professional reports, documents, images, clinical resources, or accident reports.
Control | 0..*
Type | Reference(CommunicationRequest)
Is Modifier | false
Summary | false
Requirements | Need to communicate insurer request for additional information required to support the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
446. ClaimResponse.insurance
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim.
Short | Patient insurance information
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
448. ClaimResponse.insurance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
450. ClaimResponse.insurance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
452. ClaimResponse.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
454. ClaimResponse.insurance.sequence
Definition | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Short | Insurance instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To maintain order of the coverages.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
456. ClaimResponse.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Short | Coverage to be used for adjudication
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
458. ClaimResponse.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Short | Insurance information
Control | 1..1
Type | Reference(Coverage)
Is Modifier | false
Summary | false
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
460. ClaimResponse.insurance.businessArrangement
Definition | A business agreement number established between the provider and the insurer for special business processing purposes.
Short | Additional provider contract number
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
462. ClaimResponse.insurance.claimResponse
Definition | The result of the adjudication of the line items for the Coverage specified in this insurance.
Short | Adjudication results
Comments | Must not be specified when 'focal=true' for this insurance.
Control | 0..1
Type | Reference(ClaimResponse)
Is Modifier | false
Summary | false
Requirements | An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
464. ClaimResponse.error
Definition | Errors encountered during the processing of the adjudication.
Short | Error Information
Comments | Must be populated when .outcome = 'error'
Control | 0..*
Type | BackboneElement
Is Modifier | false
Must Support | true
Summary | false
Requirements | Need to communicate processing issues to the requestor.
Label | Error Information
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
466. ClaimResponse.error.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
468. ClaimResponse.error.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
470. ClaimResponse.error.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
472. ClaimResponse.error.itemSequence
Definition | The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Item sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
474. ClaimResponse.error.detailSequence
Definition | The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Detail sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
476. ClaimResponse.error.subDetailSequence
Definition | The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Subdetail sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
478. ClaimResponse.error.code
Definition | A code identifying the reason that processing could not be completed.
Short | Reject Reason
Control | 1..1
Binding | The codes SHOULD be taken from RTPBC Error Code Value Set (preferred to `http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-error-code` ) RTPBC Error Codes
Type | CodeableConcept
Is Modifier | false
Must Support | true
Summary | false
Requirements | Required to convey processing errors.
Label | Reject Reason
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
480. ClaimResponse.error.code.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
482. ClaimResponse.error.code.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.error.code.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
484. ClaimResponse.error.code.coding
Definition | A reference to a code defined by a terminology system.
Short | Code defined by a terminology system
Comments | Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Control | 1..*
Type | Coding
Is Modifier | false
Must Support | true
Summary | true
Requirements | Allows for alternative encodings within a code system, and translations to other code systems.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
486. ClaimResponse.error.code.coding.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
488. ClaimResponse.error.code.coding.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.error.code.coding.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
490. ClaimResponse.error.code.coding.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
492. ClaimResponse.error.code.coding.version
Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Short | Version of the system - if relevant
Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
494. ClaimResponse.error.code.coding.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Reject Code
Control | 1..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to refer to a particular code in the system.
Label | Reject Code
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
496. ClaimResponse.error.code.coding.display
Definition | A representation of the meaning of the code in the system, following the rules of the system.
Short | Representation defined by the system
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
498. ClaimResponse.error.code.coding.userSelected
Definition | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Short | If this coding was chosen directly by the user
Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
500. ClaimResponse.error.code.text
Definition | Clarification of the reject cause.
Short | Reject Message
Comments | Very often the text is the same as a displayName of one of the codings.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Must Support | true
Summary | true
Requirements | The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
Label | Reject Message
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)