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

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

## Resource Profile: RTPBC Response Using ClaimResponse

Official URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse | Version: 2.0.0-ballot | Highlight text changes?
Standards status: Trial-use Active as of 2020-05-23 | Maturity Level: 2 | Computable Name: RtpbcResponseClaimResponse

This profile constrains the ClaimResponse resource to serve as the RTPBC Response in the consumer real-time pharmacy benefit check process. It uses the ClaimResponse's "predetermination" processing mode

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

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

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

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

### Must Support elements in this profile

Responding systems

- RTPBC Responders SHOULD return pricing and coverage information for relevant drug/pharmacy alternatives, in the ClaimResponse.addItem composite.§MS-CR-1
- Every RTPBC response ClaimResponse SHALL contain either an item composite or an error composite, but not both.§MS-CR-2
- The RTPBC response ClaimResponse.iItem composite SHALL be populated when sufficient information is received to be able to answer the request.§MS-CR-3

- The RTPBC response ClaimResponse.error composite SHALL be populated when the responder cannot complete processing due to insufficient or invalid information in the request.§MS-CR-4

- The benefitRestrictions extension is a conditional element that SHALL be populated in an RTPBC response ClaimResponse when the responder is an insurer (or other processor representing the patient's pharmacy benefit). It is not expected to be populated when the responder is a medication pricing source.§MS-CR-5
- The RTPBC response ClaimResponse.processNote element is a conditional element that MAY be populated when the responder has additional information about costs or coverage related to an .item or .addItem.§MS-CR-6 The noteNumber links an .item or .addItem to its associated processNote
- All elements marked Must Support are essential to communicating patient costs and coverage. The RTPBC Responder SHALL ensure that content in Must Support ClaimResponse elements is accurate and complete.§MS-CR-7

Client systems

- RTPBC Requesters SHALL be able to interpret and convey to users all cost and coverage information returned in an RTPBC response, as appropriate to the application.§MS-CR-8

Usages:

- Use this Profile: RTPBC Response Bundle
- Refer to this Profile: RTPBC Response MessageHeader
- Examples for this Profile: ClaimResponse/rtpbc-claim-response-01 and ClaimResponse/rtpbc-claim-response-not-covered

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 | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information
created | Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
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 | Payer ID Example General: 123456
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..* | 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..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.insurer.​identifier.use | Base | required | IdentifierUse | 📍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 | S | 1..1 | Reference(RTPBC Patient) | Response Patient Information
insurer | S | 1..1 | Reference(Organization) | Party responsible for reimbursement
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | Payer ID
request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | RTPBC Request ID
outcome | S | 1..1 | code | Processing Outcome
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
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..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 | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information
created | Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | 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 | Payer ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | 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..* | 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..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.insurer.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.insurer.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.insurer.​identifier.type | Base | extensible | IdentifierType | 📍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: 11 elements(22 nested mandatory elements)
Must-Support: 66 elements
Fixed: 5 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction
- http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-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 | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information
created | Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
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 | Payer ID Example General: 123456
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..* | 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..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.insurer.​identifier.use | Base | required | IdentifierUse | 📍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 | S | 1..1 | Reference(RTPBC Patient) | Response Patient Information
insurer | S | 1..1 | Reference(Organization) | Party responsible for reimbursement
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | Payer ID
request | S | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID
identifier | S | 1..1 | Identifier | Logical reference, when literal reference is not known
value | S | 1..1 | string | RTPBC Request ID
outcome | S | 1..1 | code | Processing Outcome
disposition | S | 0..1 | string | Completed Note
item | S | 0..* | BackboneElement | Requested Product and Pharmacy
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:benefitRestriction | S | 0..* | Coding | Benefit Restriction (Extension) URL: http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-benefitRestriction Binding: RTPBC Benefit Restriction Value Set (extensible)
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..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 | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information
created | Σ | 1..1 | dateTime | Response creation date
insurer | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | 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 | Payer ID Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
display | Σ | 0..1 | string | Text alternative for the resource
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | 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..* | 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..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.insurer.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
ClaimResponse.insurer.​identifier.use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
ClaimResponse.insurer.​identifier.type | Base | extensible | IdentifierType | 📍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: 11 elements(22 nested mandatory elements)
Must-Support: 66 elements
Fixed: 5 elements

Structures

This structure refers to these other structures:

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

Extensions

This structure refers to these extensions:

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