## Profile Comparison between http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse vs http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse

Left: | RTPBC Response Using ClaimResponse (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse)
Right: | RTPBC Response Using ClaimResponse (http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse)

### Messages

Error | StructureDefinition.version | Values for version differ: '1.0.0' vs '2.0.0-ballot'
Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 International - Pharmacy' vs 'HL7 International / Pharmacy'
Information | ClaimResponse.language | Example/preferred bindings differ at ClaimResponse.language using binding from RtpbcResponseClaimResponse
Information | StructureDefinition.comment | Values for comment differ: 'At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product' vs 'At least one .adjudication must contain a .category with the .code value 'total', representing the patient's total financial responsibility for the product. Note that returned balance amounts (e.g., accumulated deductible or remaining deductible) are calculated from the current member balance and reflect only the effect of the associated RTPBC request'
Information | ClaimResponse.addItem.extension | Element minimum cardinalities differ: '0' vs '1'
Information | ClaimResponse.addItem.provider | Element minimum cardinalities differ: '1' vs '0'
Information | ClaimResponse.processNote.language | Example/preferred bindings differ at ClaimResponse.processNote.language using binding from RtpbcResponseClaimResponse

### Metadata

Name | Value | Comments
--- | --- | ---
abstract | false |
baseDefinition | http://hl7.org/fhir/StructureDefinition/ClaimResponse |
copyright |  |
date | 2020-05-23T00:00:00-05:00 |
description | 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 |
experimental |  |
fhirVersion | 4.0.1 |
jurisdiction |  |
jurisdiction[0] | urn:iso:std:iso:3166#US |
kind | resource |
name | RtpbcResponseClaimResponse |
publisher | HL7 International - Pharmacy | HL7 International / Pharmacy | Values Differ
purpose |  |
status | active |
title | RTPBC Response Using ClaimResponse |
type | ClaimResponse |
url | http://hl7.org/fhir/us/carin-rtpbc/StructureDefinition/rtpbc-response-claimresponse |
version | 1.0.0 | 2.0.0-ballot | Values Differ

### Structure

Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments
--- | --- | --- | --- | --- | --- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization |
id | S Σ | 0..1 | string | Unique ClaimResponse Resource Identifier | S Σ | 0..1 | id | Unique ClaimResponse Resource Identifier |
meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language |  | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
Additional Bindings | Purpose
?? | Max Binding
|  | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
Additional Bindings | Purpose
?? | Max Binding
| Example/preferred bindings differ at ClaimResponse.language using binding from RtpbcResponseClaimResponse
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 |  | 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 |  | 0..* | Resource | Contained, inline Resources |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | S | 1..* | Identifier | RTPBC Response Identifier | S | 1..* | Identifier | RTPBC Response Identifier |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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: ?? (required): Identifies the purpose for this identifier, if known . | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known . |
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (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 | 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 | 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 | 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) | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
status | ?!S Σ | 1..1 | code | Response status Binding: ?? (required): A code specifying the state of the resource instance. Fixed Value: active | ?!S Σ | 1..1 | code | Response status Binding: ?? (required): A code specifying the state of the resource instance. Fixed Value: active |
type | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ?? (extensible): The type or discipline-style of the claim. | S Σ | 1..1 | CodeableConcept | Requested Service Type Binding: ?? (extensible): The type or discipline-style of the claim. |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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 | S Σ | 1..1 | Coding | Code defined by a terminology system |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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 | 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 | 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 | 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 | 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 | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
text | Σ | 0..1 | string | Plain text representation of the concept | Σ | 0..1 | string | Plain text representation of the concept |
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ?? (example): A more granular claim typecode. |  | 0..1 | CodeableConcept | More granular claim type Binding: ?? (example): A more granular claim typecode. |
use | S Σ | 1..1 | code | Processing Mode Binding: ?? (required): Claim, preauthorization, predetermination. Fixed Value: predetermination | S Σ | 1..1 | code | Processing Mode Binding: ?? (required): Claim, preauthorization, predetermination. Fixed Value: predetermination |
patient | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information | S Σ | 1..1 | Reference(RTPBC Patient) | Response Patient Information |
created | Σ | 1..1 | dateTime | Response creation date | Σ | 1..1 | dateTime | Response creation date |
insurer | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | S Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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 | 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: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (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 | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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: ?? (required): Identifies the purpose for this identifier, if known . | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known . |
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (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 | 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 | S Σ | 1..1 | string | Payer ID Example General: 123456 |
period | Σ | 0..1 | Period | Time period when id is/was valid for use | 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) | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
display | Σ | 0..1 | string | Text alternative for the resource | Σ | 0..1 | string | Text alternative for the resource |
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim |
request | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID | S Σ | 1..1 | Reference(Claim) | Submitter's RTPBC Request ID |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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 | 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: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (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 | S Σ | 1..1 | Identifier | Logical reference, when literal reference is not known |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 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: ?? (required): Identifies the purpose for this identifier, if known . | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known . |
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (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 | 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 | 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 | 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) | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
display | Σ | 0..1 | string | Text alternative for the resource | Σ | 0..1 | string | Text alternative for the resource |
outcome | S Σ | 1..1 | code | Processing Outcome Binding: ?? (required): The result of the claim processing. | S Σ | 1..1 | code | Processing Outcome Binding: ?? (required): The result of the claim processing. |
disposition | S | 0..1 | string | Completed Note | S | 0..1 | string | Completed Note |
preAuthRef |  | 0..1 | string | Preauthorization reference |  | 0..1 | string | Preauthorization reference |
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period |  | 0..1 | Period | Preauthorization reference effective period |
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ?? (example): A code for the party to be reimbursed. |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ?? (example): A code for the party to be reimbursed. |
item | S | 0..* | BackboneElement | Requested Product and Pharmacy | S | 0..* | BackboneElement | Requested Product and Pharmacy |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier | S | 1..1 | positiveInt | Claim item instance identifier |
noteNumber | S | 0..* | positiveInt | Determination Note Number | S | 0..* | positiveInt | Determination Note Number |
adjudication | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination | S | 1..* | BackboneElement | Requested Product and Pharmacy Determination |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: ?? (required): RTPBC Patient Pay Categories | S | 1..1 | CodeableConcept | Patient Pay Component Binding: ?? (required): RTPBC Patient Pay Categories |
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. |
amount | S | 1..1 | Money | Patient Pay Component Amount | S | 1..1 | Money | Patient Pay Component Amount |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
value | S Σ | 1..1 | decimal | Patient Pay Amount Value | S Σ | 1..1 | decimal | Patient Pay Amount Value |
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: ?? (required): Currencies | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: ?? (required): Currencies |
value |  | 0..1 | decimal | Non-monetary value |  | 0..1 | decimal | Non-monetary value |
detail |  | 0..* | BackboneElement | Adjudication for claim details |  | 0..* | BackboneElement | Adjudication for claim details |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
detailSequence |  | 1..1 | positiveInt | Claim detail instance identifier |  | 1..1 | positiveInt | Claim detail instance identifier |
noteNumber |  | 0..* | positiveInt | Applicable note numbers |  | 0..* | positiveInt | Applicable note numbers |
adjudication |  | 1..* | See adjudication | Detail level adjudication details |  | 1..* | See adjudication (ClaimResponse) | Detail level adjudication details |
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details |  | 0..* | BackboneElement | Adjudication for claim sub-details |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier |  | 1..1 | positiveInt | Claim sub-detail instance identifier |
noteNumber |  | 0..* | positiveInt | Applicable note numbers |  | 0..* | positiveInt | Applicable note numbers |
adjudication |  | 0..* | See adjudication | Subdetail level adjudication details |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details |
addItem | S | 0..* | BackboneElement | Insurer added line items | S | 0..* | BackboneElement | Insurer added line items |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url | Element minimum cardinalities differ: '0' vs '1'
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
itemSequence | S | 1..* | positiveInt | Associated request Item Sequence | S | 1..* | positiveInt | Associated request Item Sequence |
detailSequence |  | 0..* | positiveInt | Detail sequence number |  | 0..* | positiveInt | Detail sequence number |
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number |  | 0..* | positiveInt | Subdetail sequence number |
provider | S | 1..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy | S | 0..* | Reference(RTPBC Pharmacy Organization) | Priced Pharmacy | Element minimum cardinalities differ: '1' vs '0'
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
reference | S Σ C | 1..1 | string | Reference to Priced Pharmacy | S Σ C | 1..1 | string | Reference to Priced Pharmacy |
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (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 | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
display | Σ | 0..1 | string | Text alternative for the resource | Σ | 0..1 | string | Text alternative for the resource |
productOrService | S | 1..1 | CodeableConcept | Product Binding: ?? (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) | S | 1..1 | CodeableConcept | Product Binding: ?? (extensible): RTPBC prescribable product codes (NDC11 and RxNorm) |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
coding | S Σ | 1..* | Coding | Code defined by a terminology system | S Σ | 1..* | Coding | Code defined by a terminology system |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
system | S Σ | 1..1 | uri | Identity of the terminology system | S Σ | 1..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant | Σ | 0..1 | string | Version of the system - if relevant |
code | S Σ | 1..1 | code | Symbol in syntax defined by the system | S Σ | 1..1 | code | Symbol in syntax defined by the system |
display | S Σ | 1..1 | string | Product Description | S Σ | 1..1 | string | Product Description |
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
text | Σ | 0..1 | string | Plain text representation of the concept | Σ | 0..1 | string | Plain text representation of the concept |
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ?? (example): Program specific reason codes. |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ?? (example): Program specific reason codes. |
serviced[x] |  | 0..1 | date, Period | Date or dates of service or product delivery |  | 0..1 | date, Period | Date or dates of service or product delivery |
location[x] |  | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ?? (example): Place of service: pharmacy, school, prison, etc. |  | 0..1 | CodeableConcept, Address, Reference(Location) | Place of service or where product was supplied Binding: ?? (example): Place of service: pharmacy, school, prison, etc. |
quantity | S | 1..1 | ?? | Priced Quantity | S | 1..1 | ?? | Priced Quantity |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
value | S Σ | 1..1 | decimal | Quantity in Billing Units | S Σ | 1..1 | decimal | Quantity in Billing Units |
comparator | ?!Σ | 0..0 |  | < | <= | >= | > - how to understand the value Binding: ?? (required): How the Quantity should be understood and represented. | ?!Σ | 0..0 |  | < | <= | >= | > - how to understand the value Binding: ?? (required): How the Quantity should be understood and represented. |
unit | S Σ | 1..1 | string | Billing unit of measure Binding: ?? (extensible): Billing quantity unit of measure | S Σ | 1..1 | string | Billing unit of measure Binding: ?? (extensible): Billing quantity unit of measure |
system | Σ C | 0..1 | uri | System that defines coded unit form | Σ C | 0..1 | uri | System that defines coded unit form |
code | Σ | 0..1 | code | Coded form of the unit | Σ | 0..1 | code | Coded form of the unit |
unitPrice |  | 0..1 | Money | Fee, charge or cost per item |  | 0..1 | Money | Fee, charge or cost per item |
factor |  | 0..1 | decimal | Price scaling factor |  | 0..1 | decimal | Price scaling factor |
net |  | 0..1 | Money | Total item cost |  | 0..1 | Money | Total item cost |
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch. |  | 0..1 | CodeableConcept | Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch. |
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations. |  | 0..* | CodeableConcept | Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations. |
noteNumber | S | 0..* | positiveInt | Determination Note Number | S | 0..* | positiveInt | Determination Note Number |
adjudication | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination | S | 1..* | BackboneElement | Alternative Product and Pharmacy Determination |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | S | 1..1 | CodeableConcept | Patient Pay Component Binding: ?? (required): RTPBC Patient Pay Categories | S | 1..1 | CodeableConcept | Patient Pay Component Binding: ?? (required): RTPBC Patient Pay Categories |
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. |
amount | S | 1..1 | Money | Patient Pay Component Amount | S | 1..1 | Money | Patient Pay Component Amount |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
value | S Σ | 1..1 | decimal | Patient Pay Amount Value | S Σ | 1..1 | decimal | Patient Pay Amount Value |
currency | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: ?? (required): Currencies | S Σ | 1..1 | code | Patient Pay Amount Currency Binding: ?? (required): Currencies |
value |  | 0..1 | decimal | Non-monetary value |  | 0..1 | decimal | Non-monetary value |
detail |  | 0..* | BackboneElement | Insurer added line details |  | 0..* | BackboneElement | Insurer added line details |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. |
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |
quantity |  | 0..1 | ?? | Count of products or services |  | 0..1 | ?? | Count of products or services |
unitPrice |  | 0..1 | Money | Fee, charge or cost per item |  | 0..1 | Money | Fee, charge or cost per item |
factor |  | 0..1 | decimal | Price scaling factor |  | 0..1 | decimal | Price scaling factor |
net |  | 0..1 | Money | Total item cost |  | 0..1 | Money | Total item cost |
noteNumber |  | 0..* | positiveInt | Applicable note numbers |  | 0..* | positiveInt | Applicable note numbers |
adjudication |  | 1..* | See adjudication | Added items detail adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication |
subDetail |  | 0..* | BackboneElement | Insurer added line items |  | 0..* | BackboneElement | Insurer added line items |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. |
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. |
quantity |  | 0..1 | ?? | Count of products or services |  | 0..1 | ?? | Count of products or services |
unitPrice |  | 0..1 | Money | Fee, charge or cost per item |  | 0..1 | Money | Fee, charge or cost per item |
factor |  | 0..1 | decimal | Price scaling factor |  | 0..1 | decimal | Price scaling factor |
net |  | 0..1 | Money | Total item cost |  | 0..1 | Money | Total item cost |
noteNumber |  | 0..* | positiveInt | Applicable note numbers |  | 0..* | positiveInt | Applicable note numbers |
adjudication |  | 1..* | See adjudication | Added items detail adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication |
adjudication |  | 0..* | See adjudication | Header-level adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication |
total | Σ | 0..* | BackboneElement | Adjudication totals | Σ | 0..* | BackboneElement | Adjudication totals |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: ?? (example): The adjudication codes. | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: ?? (example): The adjudication codes. |
amount | Σ | 1..1 | Money | Financial total for the category | Σ | 1..1 | Money | Financial total for the category |
payment |  | 0..1 | BackboneElement | Payment Details |  | 0..1 | BackboneElement | Payment Details |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment. |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment. |
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues |  | 0..1 | Money | Payment adjustment for non-claim issues |
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: ?? (example): Payment Adjustment reason codes. |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: ?? (example): Payment Adjustment reason codes. |
date |  | 0..1 | date | Expected date of payment |  | 0..1 | date | Expected date of payment |
amount |  | 1..1 | Money | Payable amount after adjustment |  | 1..1 | Money | Payable amount after adjustment |
identifier |  | 0..1 | Identifier | Business identifier for the payment |  | 0..1 | Identifier | Business identifier for the payment |
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None). |  | 0..1 | CodeableConcept | Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None). |
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: ?? (example): The forms codes. |  | 0..1 | CodeableConcept | Printed form identifier Binding: ?? (example): The forms codes. |
form |  | 0..1 | Attachment | Printed reference or actual form |  | 0..1 | Attachment | Printed reference or actual form |
processNote | S | 0..* | BackboneElement | Determination Note | S | 0..* | BackboneElement | Determination Note |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
number | S | 1..1 | positiveInt | Determination Note Number | S | 1..1 | positiveInt | Determination Note Number |
type |  | 0..1 | code | display | print | printoper Binding: ?? (required): The presentation types of notes. |  | 0..1 | code | display | print | printoper Binding: ?? (required): The presentation types of notes. |
text | S | 1..1 | string | Determination Note Text | S | 1..1 | string | Determination Note Text |
language |  | 0..1 | CodeableConcept | Language of the text Binding: ?? (preferred): A human language.
Additional Bindings | Purpose
?? | Max Binding
|  | 0..1 | CodeableConcept | Language of the text Binding: ?? (preferred): A human language.
Additional Bindings | Purpose
?? | Max Binding
| Example/preferred bindings differ at ClaimResponse.processNote.language using binding from RtpbcResponseClaimResponse
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information |  | 0..* | Reference(CommunicationRequest) | Request for additional information |
insurance |  | 0..* | BackboneElement | Patient insurance information |  | 0..* | BackboneElement | Patient insurance information |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
sequence |  | 1..1 | positiveInt | Insurance instance identifier |  | 1..1 | positiveInt | Insurance instance identifier |
focal |  | 1..1 | boolean | Coverage to be used for adjudication |  | 1..1 | boolean | Coverage to be used for adjudication |
coverage |  | 1..1 | Reference(Coverage) | Insurance information |  | 1..1 | Reference(Coverage) | Insurance information |
businessArrangement |  | 0..1 | string | Additional provider contract number |  | 0..1 | string | Additional provider contract number |
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results |  | 0..1 | Reference(ClaimResponse) | Adjudication results |
error | S | 0..* | BackboneElement | Error Information | S | 0..* | BackboneElement | Error Information |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
extension |  | 0..* | Extension | Additional content defined by implementations |  | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
itemSequence |  | 0..1 | positiveInt | Item sequence number |  | 0..1 | positiveInt | Item sequence number |
detailSequence |  | 0..1 | positiveInt | Detail sequence number |  | 0..1 | positiveInt | Detail sequence number |
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number |  | 0..1 | positiveInt | Subdetail sequence number |
code | S | 1..1 | CodeableConcept | Reject Reason Binding: ?? (preferred): RTPBC Error Codes | S | 1..1 | CodeableConcept | Reject Reason Binding: ?? (preferred): RTPBC Error Codes |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
coding | S Σ | 1..* | Coding | Code defined by a terminology system | S Σ | 1..* | Coding | Code defined by a terminology system |
id |  | 0..1 | string | Unique id for inter-element referencing |  | 0..1 | string | Unique id for inter-element referencing |
Slices for extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
system | S Σ | 1..1 | uri | Identity of the terminology system | S Σ | 1..1 | uri | Identity of the terminology system |
version | Σ | 0..1 | string | Version of the system - if relevant | Σ | 0..1 | string | Version of the system - if relevant |
code | S Σ | 1..1 | code | Reject Code | S Σ | 1..1 | code | Reject Code |
display | S Σ | 1..1 | string | Representation defined by the system | S Σ | 1..1 | string | Representation defined by the system |
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
text | S Σ | 0..1 | string | Reject Message | S Σ | 0..1 | string | Reject Message |
Documentation for this format