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 Non-PHI Response Using ClaimResponse

Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse-non-phi | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Trial-use Active as of 2026-02-17 | Maturity Level: 2 | Computable Name: RtpbcResponseClaimResponseNonPHI

This profile omits persoanlly-identifiable content in an RTPBC response. To be used by data sources that can provide benefit or price information without receiving patient details.

Usages:

- Use this Profile: RTPBC Response Bundle Non-PHI
- Refer to this Profile: RTPBC Non-PHI Response MessageHeader
- Examples for this Profile: ClaimResponse/rtpbc-claim-response-discount-card and ClaimResponse/rtpbc-claim-response-price-source

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | S Σ | 0..1 | id | Unique ClaimResponse Resource Identifier
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..* | Identifier | RTPBC Response Identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Unique RTPBC response ID Example General: 123456
status | ?!S Σ | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient | Σ | 1..1 | Reference(Patient) | Patient information (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
created | Σ | 1..1 | dateTime | Response creation date
insurer | Σ | 1..1 | Reference(Organization) | Insurer (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
request | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | RTPBC Request ID Example General: 123456
outcome | S Σ | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
reference | S Σ C | 1..1 | string | Reference to Priced Pharmacy
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote | S | 0..* | BackboneElement | Determination Note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Determination Note Number
text | S | 1..1 | string | Determination Note Text
error | S | 0..* | BackboneElement | Error Information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Reject Code
display | S Σ | 1..1 | string | Representation defined by the system
text | S Σ | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.patient.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
id | S | 0..1 | id | Unique ClaimResponse Resource Identifier
identifier | S | 1..* | Identifier | RTPBC Response Identifier
value | S | 1..1 | string | Unique RTPBC response ID
status | S | 1..1 | code | Response status Fixed Value: active
type | S | 1..1 | CodeableConcept | Requested Service Type
coding | S | 1..1 | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S | 1..1 | code | Processing Mode Fixed Value: predetermination
patient |  | 1..1 | Reference(Patient) | Patient information (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..1 | Identifier | Unique, non-personally identifiable code
display |  | 0..0 |  | Text alternative for the resource
insurer |  | 1..1 | Reference(Organization) | Insurer (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | RTPBC Request ID
outcome | S | 1..1 | code | Processing Outcome
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S | 1..1 | decimal | Patient Pay Amount Value
currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
reference | S | 1..1 | string | Reference to Priced Pharmacy
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding | S | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
display | S | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
value | S | 1..1 | decimal | Quantity in Billing Units
unit | S | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S | 1..1 | decimal | Patient Pay Amount Value
currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote | S | 0..* | BackboneElement | Determination Note
number | S | 1..1 | positiveInt | Determination Note Number
text | S | 1..1 | string | Determination Note Text
error | S | 0..* | BackboneElement | Error Information
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding | S | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Reject Code
display | S | 1..1 | string | Representation defined by the system
text | S | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | S Σ | 0..1 | id | Unique ClaimResponse Resource Identifier
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..* | Identifier | RTPBC Response Identifier
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Unique RTPBC response ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient | Σ | 1..1 | Reference(Patient) | Patient information (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
created | Σ | 1..1 | dateTime | Response creation date
insurer | Σ | 1..1 | Reference(Organization) | Insurer (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | RTPBC Request ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
outcome | S Σ | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition | S | 0..1 | string | Completed Note
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount | S | 1..1 | Money | Patient Pay Component Amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem | S | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Reference to Priced Pharmacy
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system | Σ C | 0..1 | uri | System that defines coded unit form
code | Σ | 0..1 | code | Coded form of the unit
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount | S | 1..1 | Money | Patient Pay Component Amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote | S | 0..* | BackboneElement | Determination Note
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Determination Note Number
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text | S | 1..1 | string | Determination Note Text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error | S | 0..* | BackboneElement | Error Information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Reject Code
display | S Σ | 1..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | S Σ | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.patient.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​provider.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Summary

Mandatory: 13 elements(22 nested mandatory elements)
Must-Support: 66 elements
Fixed: 7 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | S Σ | 0..1 | id | Unique ClaimResponse Resource Identifier
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..* | Identifier | RTPBC Response Identifier
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | Unique RTPBC response ID Example General: 123456
status | ?!S Σ | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient | Σ | 1..1 | Reference(Patient) | Patient information (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
created | Σ | 1..1 | dateTime | Response creation date
insurer | Σ | 1..1 | Reference(Organization) | Insurer (masked)
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
request | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
value | S Σ | 1..1 | string | RTPBC Request ID Example General: 123456
outcome | S Σ | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
reference | S Σ C | 1..1 | string | Reference to Priced Pharmacy
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote | S | 0..* | BackboneElement | Determination Note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Determination Note Number
text | S | 1..1 | string | Determination Note Text
error | S | 0..* | BackboneElement | Error Information
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding | S Σ | 1..* | Coding | Code defined by a terminology system
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Reject Code
display | S Σ | 1..1 | string | Representation defined by the system
text | S Σ | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.patient.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
id | S | 0..1 | id | Unique ClaimResponse Resource Identifier
identifier | S | 1..* | Identifier | RTPBC Response Identifier
value | S | 1..1 | string | Unique RTPBC response ID
status | S | 1..1 | code | Response status Fixed Value: active
type | S | 1..1 | CodeableConcept | Requested Service Type
coding | S | 1..1 | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
use | S | 1..1 | code | Processing Mode Fixed Value: predetermination
patient |  | 1..1 | Reference(Patient) | Patient information (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
reference |  | 0..0 |  | Literal reference, Relative, internal or absolute URL
type |  | 0..0 |  | Type the reference refers to (e.g. "Patient")
identifier |  | 0..1 | Identifier | Unique, non-personally identifiable code
display |  | 0..0 |  | Text alternative for the resource
insurer |  | 1..1 | Reference(Organization) | Insurer (masked)
extension | S | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
value[x] |  | 1..1 | code | Value of extension Fixed Value: masked
request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | RTPBC Request ID
outcome | S | 1..1 | code | Processing Outcome
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S | 1..1 | decimal | Patient Pay Amount Value
currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
addItem | S | 0..* | BackboneElement | Insurer added line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
reference | S | 1..1 | string | Reference to Priced Pharmacy
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
coding | S | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
display | S | 1..1 | string | Product Description
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
value | S | 1..1 | decimal | Quantity in Billing Units
unit | S | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
amount | S | 1..1 | Money | Patient Pay Component Amount
value | S | 1..1 | decimal | Patient Pay Amount Value
currency | S | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
processNote | S | 0..* | BackboneElement | Determination Note
number | S | 1..1 | positiveInt | Determination Note Number
text | S | 1..1 | string | Determination Note Text
error | S | 0..* | BackboneElement | Error Information
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
coding | S | 1..* | Coding | Code defined by a terminology system
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Reject Code
display | S | 1..1 | string | Representation defined by the system
text | S | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

Snapshot ViewView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | S Σ | 0..1 | id | Unique ClaimResponse Resource Identifier
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | S | 1..* | Identifier | RTPBC Response Identifier
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | Unique RTPBC response ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
status | ?!S Σ | 1..1 | code | Response status Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Fixed Value: active
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..1 | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: pharmacy
display | S Σ | 1..1 | string | Representation defined by the system Fixed Value: Pharmacy
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | S Σ | 1..1 | code | Processing Mode Binding: Use (required): Claim, preauthorization, predetermination. Fixed Value: predetermination
patient | Σ | 1..1 | Reference(Patient) | Patient information (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
identifier | Σ | 0..1 | Identifier | Unique, non-personally identifiable code
created | Σ | 1..1 | dateTime | Response creation date
insurer | Σ | 1..1 | Reference(Organization) | Insurer (masked)
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension | S | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:data-masked | S | 1..1 | (Complex) | unknown | asked | temp | notasked | masked | unsupported | astext | error URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/data-absent-reason"
value[x] |  | 1..1 | code | Value of extension Binding: DataAbsentReason (required) Fixed Value: masked
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | S Σ | 1..1 | string | RTPBC Request ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
outcome | S Σ | 1..1 | code | Processing Outcome Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition | S | 0..1 | string | Completed Note
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..1 | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..1 | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..1 | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount | S | 1..1 | Money | Patient Pay Component Amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | Claim detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem | S | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:isAlternative | S | 1..1 | boolean | Is Alternative (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
extension:formularyStatus | S | 0..* | Coding | Formulary Status (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus Binding: RTPBC Formulary Status Value Set (extensible)
extension:preferenceLevel | S | 0..* | positiveInt | Preference Level (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
extension:nextAvailableFillDate | S | 0..* | date | Next Available Fill Date (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
extension:relatedCoverage | S | 0..* | Reference(RTPBC Coverage | RTPBC Coverage - Non-PHI) | Related Coverage (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 1..1 | string | Reference to Priced Pharmacy
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
productOrService | S | 1..1 | CodeableConcept | Product Binding: RTPBC Prescribable Product Code Value Set (extensible): RTPBC prescribable product codes (NDC11 and RxNorm)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | S Σ | 1..1 | string | Product Description
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity | S | 1..1 | SimpleQuantity(4.0.1) | Priced Quantity
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Quantity in Billing Units
unit | S Σ | 1..1 | string | Billing unit of measure Binding: RTPBC Billing Unit Value Set (extensible): Billing quantity unit of measure
system | Σ C | 0..1 | uri | System that defines coded unit form
code | Σ | 0..1 | code | Coded form of the unit
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber | S | 0..* | positiveInt | Determination Note Number
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: RTPBC Patient Pay Type Value Set (required): RTPBC Patient Pay Categories
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount | S | 1..1 | Money | Patient Pay Component Amount
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
value | S Σ | 1..1 | decimal | Patient Pay Amount Value
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: Currencies (required): Currencies
value |  | 0..1 | decimal | Non-monetary value
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote | S | 0..* | BackboneElement | Determination Note
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number | S | 1..1 | positiveInt | Determination Note Number
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text | S | 1..1 | string | Determination Note Text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error | S | 0..* | BackboneElement | Error Information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code | S | 1..1 | CodeableConcept | Reject Reason Binding: RTPBC Error Code Value Set (preferred): RTPBC Error Codes
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 1..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Reject Code
display | S Σ | 1..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | S Σ | 0..1 | string | Reject Message
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
ClaimResponse.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.identifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.status | Base | required | Financial Resource Status Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.type | Base | extensible | Claim Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.subType | Base | example | Example Claim SubType Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.use | Base | required | Use | 📍4.0.1 | FHIR Std.
ClaimResponse.patient.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​extension:data-masked.​value[x] | Base | required | DataAbsentReason | 📦4.0.1 | FHIR Std.
ClaimResponse.insurer.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.request.​identifier.type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
ClaimResponse.outcome | Base | required | Claim Processing Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payeeType | Base | example | PayeeType | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.item.adjudication.​reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.item.adjudication.​amount.currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​provider.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​productOrService | Base | extensible | RTPBC Prescribable Product Code Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​programCode | Base | example | Example Program Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​location[x] | Base | example | Example Service Place Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​quantity.unit | Base | extensible | RTPBC Billing Unit Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​bodySite | Base | example | Oral Site Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​subSite | Base | example | Surface Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.category | Base | required | RTPBC Patient Pay Type Value Set | 📦2.0.0-ballot | This IG
ClaimResponse.addItem.​adjudication.reason | Base | example | Adjudication Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​adjudication.amount.​currency | Base | required | CurrencyCode | 📦4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService | Base | example | USCLS Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier | Base | example | Modifier type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.total.​category | Base | example | Adjudication Value Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​type | Base | example | Example Payment Type Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.payment.​adjustmentReason | Base | example | Payment Adjustment Reason Codes | 📍4.0.1 | FHIR Std.
ClaimResponse.fundsReserve | Base | example | FundsReserve | 📍4.0.1 | FHIR Std.
ClaimResponse.formCode | Base | example | Forms | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​type | Base | required | NoteType | 📍4.0.1 | FHIR Std.
ClaimResponse.processNote.​language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
ClaimResponse.error.​code | Base | preferred | RTPBC Error Code Value Set | 📦2.0.0-ballot | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Summary

Mandatory: 13 elements(22 nested mandatory elements)
Must-Support: 66 elements
Fixed: 7 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/data-absent-reason|5.2.0
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-formularyStatus
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-preferenceLevel
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-nextAvailableFillDate
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-relatedCoverage
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-isAlternative

Maturity: 2

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