Da Vinci Prior Authorization Support (PAS) FHIR IG
2.2.0-ballot - STU 2.2 - Ballot United States of America flag

Da Vinci Prior Authorization Support (PAS) FHIR IG, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.2.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-pas/ and changes regularly. See the Directory of published versions

Resource Profile: PASClaimResponse - Detailed Descriptions

Page standards status: Trial-use Maturity Level: 3

Definitions for the profile-claimresponse resource profile.

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

0. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

ShortResponse to a preauthorizationResponse to a claim predetermination or preauthorization
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. ClaimResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. ClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

ShortBusiness Identifier for a claim response
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier(PAS Identifier)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows claim responses to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.identifier.extension:subDepartment
Slice NamesubDepartment
Definition

An additional element that provides a further subdivision within the organization granting the identifier.

ShortExtension
Control0..1
TypeExtension(IdentifierSubDepartment) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. ClaimResponse.identifier.extension:jurisdiction
Slice Namejurisdiction
Definition

An additional element that provides the assigning jurisdiction of the identifier (i.e. provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.

ShortExtension
Control0..1
TypeExtension(IdentifierJurisdiction) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
12. ClaimResponse.identifier.use
Definition

The purpose of this identifier.

Shortusual | official | temp | secondary | old (If known)
Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control0..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ClaimResponse.identifier.system
Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

ShortShould use a scheme of 'urn:trnorg:<TRN03>'The namespace for the identifier value
Comments

Identifier.system is always case sensitive.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ClaimResponse.identifier.value
Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

ShortThe value that is unique
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Example<br/><b>General</b>:123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. ClaimResponse.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

Pattern Valueactive
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.type
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Some jurisdictions need a finer grained claim type for routing and adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ClaimResponse.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Claim, preauthorization, predetermination.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

This element is required to understand the nature of the request for adjudication.

Pattern Valuepreauthorization
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ClaimResponse.patient
Definition

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

ShortThe recipient of the products and services
Control1..1
TypeReference(PAS Beneficiary Patient, Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ClaimResponse.created
Definition

The date this resource was created.

ShortResponse creation date
Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortParty responsible for reimbursement
Control1..1
TypeReference(PAS Insurer Organization, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ClaimResponse.requestor
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

ShortParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control0..1
TypeReference(PAS Requestor Organization, PAS PractitionerRole, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ClaimResponse.request
Definition

Original request resource reference.

ShortId of resource triggering adjudication
Control10..1
TypeReference(PAS Claim, Claim)
Is Modifierfalse
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ClaimResponse.request.extension:DataAbsentReason
Slice NameDataAbsentReason
Definition

Provides a reason why the expected value or elements in the element that is extended are missing.

Shortunknown | asked | temp | notasked | masked | unsupported | astext | error
Control0..1
TypeExtension(Data Absent Reason) (Extension Type: code)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
36. ClaimResponse.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Shortqueued | complete | error | partial
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

The result of the claim processing.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ClaimResponse.preAuthPeriod
Definition

The time frame during which this authorization is effective.

ShortPreauthorization reference effective period
Control0..1
TypePeriod
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ClaimResponse.item
Definition

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

ShortAdjudication for claim line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The adjudication for items provided on the claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ClaimResponse.item.extension:itemTraceNumber
Slice NameitemTraceNumber
Definition

Uniquely identifies this claim item. (2000F-TRN)

ShortUniquely identifies this claim item. (2000F-TRN)
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. ClaimResponse.item.extension:preAuthIssueDate
Slice NamepreAuthIssueDate
Definition

The date when this item's preauthorization was issued.

ShortThe date when this item's preauthorization was issued.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. ClaimResponse.item.extension:preAuthPeriod
Slice NamepreAuthPeriod
Definition

The date/period when this item's preauthorization is valid.

ShortThe date/period when this item's preauthorization is valid.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
48. ClaimResponse.item.extension:previousAuthorizationNumber
Slice NamepreviousAuthorizationNumber
Definition

A string assigned by the UMO to an authorized review outcome associated with this service item.

ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AuthorizationNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
50. ClaimResponse.item.extension:administrationReferenceNumber
Slice NameadministrationReferenceNumber
Definition

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
52. ClaimResponse.item.extension:requestedServiceDate
Slice NamerequestedServiceDate
Definition

The original date/period that was requested by the submitter for this item.

ShortThe original date/period that was requested by the submitter for this item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemRequestedServiceDate) (Extension Type: Choice of: dateTime, Period)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
54. ClaimResponse.item.extension:authorizedProvider
Slice NameauthorizedProvider
Definition

The specific provider who has been authorized to provide this item.

ShortThe specific provider who has been authorized to provide this item.
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemAuthorizedProvider) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
56. ClaimResponse.item.extension:authorizedItemDetail
Slice NameauthorizedItemDetail
Definition

The details of what has been authorized for this item.

ShortThe details of what has been authorized for this item.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemAuthorizedDetail) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
58. ClaimResponse.item.extension:communicatedDiagnosis
Slice NamecommunicatedDiagnosis
Definition

A code representing the diagnosis that is the subject of the communication

ShortA code representing the diagnosis that is relevant to the preauthorization.
Control0..*
TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
60. ClaimResponse.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
62. ClaimResponse.item.itemSequence
Definition

A number to uniquely reference the claim item entries.

ShortSequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponseClaim item instance identifier
Comments

Each item returned on the PAS ClaimResponse SHALL echo the same item sequence number as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.

Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. ClaimResponse.item.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. ClaimResponse.item.adjudication
Definition

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

ShortAdjudication details
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. ClaimResponse.item.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
70. ClaimResponse.item.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
72. ClaimResponse.item.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. ClaimResponse.addItem
Definition

The first-tier service adjudications for payor added product or service lines.

ShortInsurer added line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. ClaimResponse.addItem.extension:itemTraceNumber
Slice NameitemTraceNumber
Definition

Uniquely identifies this claim item. (2000F-TRN)

ShortExtension
Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
78. ClaimResponse.addItem.extension:preAuthIssueDate
Slice NamepreAuthIssueDate
Definition

The date when this item's preauthorization was issued.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. ClaimResponse.addItem.extension:preAuthPeriod
Slice NamepreAuthPeriod
Definition

The date/period when this item's preauthorization is valid.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. ClaimResponse.addItem.extension:previousAuthorizationNumber
Slice NamepreviousAuthorizationNumber
Definition

A string assigned by the UMO to an authorized review outcome associated with this service item.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AuthorizationNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. ClaimResponse.addItem.extension:administrationReferenceNumber
Slice NameadministrationReferenceNumber
Definition

A string assigned by the UMO to the original disallowed review outcome associated with this service item.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
86. ClaimResponse.addItem.extension:epsdtIndicator
Slice NameepsdtIndicator
Definition

An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(EPSDTIndicator) (Extension Type: boolean)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
88. ClaimResponse.addItem.extension:nursingHomeResidentialStatus
Slice NamenursingHomeResidentialStatus
Definition

A code specifying the status of a nursing home resident at the time of service. (SV209)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(NursingHomeResidentialStatus) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
90. ClaimResponse.addItem.extension:nursingHomeLevelOfCare
Slice NamenursingHomeLevelOfCare
Definition

A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(NursingHomeLevelOfCare) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. ClaimResponse.addItem.extension:productOrServiceCodeEnd
Slice NameproductOrServiceCodeEnd
Definition

Used to provide the last code in a series of codes for the service being requested.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ProductOrServiceCodeEnd) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. ClaimResponse.addItem.extension:revenue
Slice Namerevenue
Definition

A revenue code that expresses what was approved which maps to X12 SV201

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RevenueCode) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
96. ClaimResponse.addItem.extension:revenueUnitRateLimit
Slice NamerevenueUnitRateLimit
Definition

The limit on the rate per unit of revenue for hospital accomodation. (SV206)

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RevenueUnitRateLimit) (Extension Type: decimal)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
98. ClaimResponse.addItem.extension:requestedService
Slice NamerequestedService
Definition

The details of the service being requested.

ShortExtension
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(RequestedService) (Extension Type: Reference(PAS Medication Request, PAS Service Request, PAS Device Request, PAS Nutrition Order))
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
100. ClaimResponse.addItem.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
102. ClaimResponse.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

ShortItem sequence number
Control10..1*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Provides references to the claim items.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. ClaimResponse.addItem.provider
Definition

The providers who are authorized for the services rendered to the patient.

ShortAuthorized providers
Control0..*
TypeReference(PAS Practitioner, PAS Organization Base Profile, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. ClaimResponse.addItem.provider.extension:providerType
Slice NameproviderType
Definition

The type of provider who has been authorized to provide this item.

ShortExtension
Control0..1
TypeExtension(AuthorizedProviderType) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
108. ClaimResponse.addItem.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortBilling, service, product, or drug code
Comments

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Control1..1
BindingThe codes SHALL be taken from For example codes, see X12 278 Requested Service Typehttp://hl7.org/fhir/ValueSet/service-uscls
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Necessary to state what was provided or done.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. ClaimResponse.addItem.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

ShortService/Product billing modifiers
Comments

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Control0..*
BindingThe codes SHALL be taken from For example codes, see X12 278 Requested Service Modifier Typehttp://hl7.org/fhir/ValueSet/claim-modifiers
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. ClaimResponse.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

ShortDate or dates of service or product delivery
Control0..1
TypeChoice of: date, Period
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. ClaimResponse.addItem.location[x]
Definition

Where the product or service was provided.

ShortPlace of service or where product was supplied
Control0..1
BindingFor example codes, see ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place
(example to http://hl7.org/fhir/ValueSet/service-place)

Place of service: pharmacy, school, prison, etc.

TypeChoice of: CodeableConcept, Address, Reference(Location)
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Must Supporttrue
Must Support TypesNo must-support rules about the choice of types/profiles
Summaryfalse
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ClaimResponse.addItem.quantity
Definition

The number of repetitions of a service or product.

ShortCount of products or services
Control0..1
TypeQuantity(PAS Quantity, SimpleQuantity)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. ClaimResponse.addItem.unitPrice
Definition

If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

ShortFee, charge or cost per item
Control0..1
TypeMoney
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The amount charged to the patient by the provider for a single unit.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. ClaimResponse.addItem.adjudication
Definition

The adjudication results.

ShortAdded items adjudication
Control1..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. ClaimResponse.addItem.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
124. ClaimResponse.addItem.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
126. ClaimResponse.addItem.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. ClaimResponse.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

ShortHeader-level adjudication
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. ClaimResponse.adjudication.extension:reviewAction
Slice NamereviewAction
Definition

The details of the review action that is necessary for the authorization.

ShortThe details of the review action that is necessary for the authorization.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ReviewAction) (Complex Extension)
Is Modifierfalse
Must Supporttrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
132. ClaimResponse.adjudication.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
134. ClaimResponse.adjudication.category
Definition

A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.Type of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Pattern Value{
  "coding" : [{
    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
    "code" : "submitted"
  }]
}
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. ClaimResponse.processNote
Definition

A note that describes or explains adjudication results in a human readable form.

ShortNote concerning adjudication
Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Provides the insurer specific textual explanations associated with the processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. ClaimResponse.processNote.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
140. ClaimResponse.processNote.number
Definition

A number to uniquely identify a note entry.

ShortNote instance identifier
Control10..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to provide a mechanism to link from adjudications.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. ClaimResponse.processNote.text
Definition

The explanation or description associated with the processing.

ShortNote explanatory text
Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Required to provide human readable explanation.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
144. ClaimResponse.communicationRequest
Definition

Request for additional supporting or authorizing information.

ShortRequest for additional information
Comments

For example: professional reports, documents, images, clinical resources, or accident reports.

Control0..*
TypeReference(PAS CommunicationRequest, CommunicationRequest)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Need to communicate insurer request for additional information required to support the adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. ClaimResponse.error
Definition

Errors encountered during the processing of the adjudication.

ShortProcessing errors
Comments

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Control0..*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Need to communicate processing issues to the requestor.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. ClaimResponse.error.extension:followupAction
Slice NamefollowupAction
Definition

A code representing what action must occur to resolve this error.

ShortA code representing what action must occur to resolve this error.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorFollowupAction) (Extension Type: CodeableConcept)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
150. ClaimResponse.error.extension:errorElement
Slice NameerrorElement
Definition

The specific loop, segment, or element that this error information is about. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103

ShortThe specific X12 loop, segment, or element that this error information is about.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorElement) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
152. ClaimResponse.error.extension:errorPath
Slice NameerrorPath
Definition

The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element.

STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element.

Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value

ShortThe FHIRPath expression that indicates which FHIR element that this error information is about.
Control0..1
This element is affected by the following invariants: ele-1
TypeExtension(ErrorPath) (Extension Type: string)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
154. ClaimResponse.error.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
156. ClaimResponse.error.code
Definition

An error code, from a specified code system, which details why the claim could not be adjudicated.

ShortError code detailing processing issues
Control1..1
BindingThe codes SHALL be taken from For example codes, see X12 278 Reject Reason Value Sethttp://hl7.org/fhir/ValueSet/adjudication-error
(required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes)
TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required to convey processing errors.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

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

0. ClaimResponse
2. ClaimResponse.item
4. ClaimResponse.item.extension:communicatedDiagnosis
Slice NamecommunicatedDiagnosis
ShortA code representing the diagnosis that is relevant to the preauthorization.
Control0..*
TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
Must Supporttrue
6. ClaimResponse.communicationRequest
TypeReference(PAS CommunicationRequest)
Must Supporttrue

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

0. ClaimResponse
Definition

This resource provides the adjudication details from the processing of a Claim resource.

ShortResponse to a preauthorization
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. ClaimResponse.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. ClaimResponse.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ClaimResponse.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. ClaimResponse.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. ClaimResponse.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. ClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

ShortBusiness Identifier for a claim response
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier(PAS Identifier)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows claim responses to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.identifier.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
22. ClaimResponse.identifier.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on ClaimResponse.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 24. ClaimResponse.identifier.extension:subDepartment
    Slice NamesubDepartment
    Definition

    An additional element that provides a further subdivision within the organization granting the identifier.

    ShortExtension
    Control0..1
    TypeExtension(IdentifierSubDepartment) (Extension Type: string)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    26. ClaimResponse.identifier.extension:jurisdiction
    Slice Namejurisdiction
    Definition

    An additional element that provides the assigning jurisdiction of the identifier (i.e. provider state license number or state driver's license) so that it does not need to be mapped from the identifier system.

    ShortExtension
    Control0..1
    TypeExtension(IdentifierJurisdiction) (Extension Type: CodeableConcept)
    Is Modifierfalse
    Must Supporttrue
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    28. ClaimResponse.identifier.use
    Definition

    The purpose of this identifier.

    Shortusual | official | temp | secondary | old (If known)
    Comments

    Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

    Control0..1
    BindingThe codes SHALL be taken from IdentifierUse
    (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

    Identifies the purpose for this identifier, if known .

    Typecode
    Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. ClaimResponse.identifier.type
    Definition

    A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

    ShortDescription of identifier
    Comments

    This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
    (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

    A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Allows users to make use of identifiers when the identifier system is not known.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. ClaimResponse.identifier.system
    Definition

    Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

    ShortShould use a scheme of 'urn:trnorg:<TRN03>'
    Comments

    Identifier.system is always case sensitive.

    Control1..1
    Typeuri
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

    Example<br/><b>General</b>:http://www.acme.com/identifiers/patient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. ClaimResponse.identifier.value
    Definition

    The portion of the identifier typically relevant to the user and which is unique within the context of the system.

    ShortThe value that is unique
    Comments

    If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

    Control1..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Example<br/><b>General</b>:123456
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. ClaimResponse.identifier.period
    Definition

    Time period during which identifier is/was valid for use.

    ShortTime period when id is/was valid for use
    Control0..1
    TypePeriod
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. ClaimResponse.identifier.assigner
    Definition

    Organization that issued/manages the identifier.

    ShortOrganization that issued id (may be just text)
    Comments

    The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

    Control0..1
    TypeReference(Organization)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. ClaimResponse.status
    Definition

    The status of the resource instance.

    Shortactive | cancelled | draft | entered-in-error
    Comments

    This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

    Control1..1
    BindingThe codes SHALL be taken from FinancialResourceStatusCodes
    (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

    A code specifying the state of the resource instance.

    Typecode
    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

    Pattern Valueactive
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    42. ClaimResponse.type
    Definition

    A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

    ShortMore granular claim type
    Comments

    This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
    (extensible to http://hl7.org/fhir/ValueSet/claim-type)

    The type or discipline-style of the claim.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Some jurisdictions need a finer grained claim type for routing and adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    44. ClaimResponse.subType
    Definition

    A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

    ShortMore granular claim type
    Comments

    This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

    Control0..1
    BindingFor example codes, see ExampleClaimSubTypeCodes
    (example to http://hl7.org/fhir/ValueSet/claim-subtype)

    A more granular claim typecode.

    TypeCodeableConcept
    Is Modifierfalse
    Summaryfalse
    Requirements

    Some jurisdictions need a finer grained claim type for routing and adjudication.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    46. ClaimResponse.use
    Definition

    A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

    Shortclaim | preauthorization | predetermination
    Control1..1
    BindingThe codes SHALL be taken from Use
    (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

    Claim, preauthorization, predetermination.

    Typecode
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    This element is required to understand the nature of the request for adjudication.

    Pattern Valuepreauthorization
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    48. ClaimResponse.patient
    Definition

    The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

    ShortThe recipient of the products and services
    Control1..1
    TypeReference(PAS Beneficiary Patient)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    50. ClaimResponse.created
    Definition

    The date this resource was created.

    ShortResponse creation date
    Control1..1
    TypedateTime
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to record a timestamp for use by both the recipient and the issuer.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    52. ClaimResponse.insurer
    Definition

    The party responsible for authorization, adjudication and reimbursement.

    ShortParty responsible for reimbursement
    Control1..1
    TypeReference(PAS Insurer Organization)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    54. ClaimResponse.requestor
    Definition

    The provider which is responsible for the claim, predetermination or preauthorization.

    ShortParty responsible for the claim
    Comments

    Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

    Control0..1
    TypeReference(PAS Requestor Organization, PAS PractitionerRole)
    Is Modifierfalse
    Must Supporttrue
    Must Support TypesNo must-support rules about the choice of types/profiles
    Summaryfalse
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    56. ClaimResponse.request
    Definition

    Original request resource reference.

    ShortId of resource triggering adjudication
    Control1..1
    TypeReference(PAS Claim)
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    58. ClaimResponse.request.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    60. ClaimResponse.request.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on ClaimResponse.request.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 62. ClaimResponse.request.extension:DataAbsentReason
      Slice NameDataAbsentReason
      Definition

      Provides a reason why the expected value or elements in the element that is extended are missing.

      Shortunknown | asked | temp | notasked | masked | unsupported | astext | error
      Control0..1
      TypeExtension(Data Absent Reason) (Extension Type: code)
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      64. ClaimResponse.request.reference
      Definition

      A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

      ShortLiteral reference, Relative, internal or absolute URL
      Comments

      Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

      Control0..1
      This element is affected by the following invariants: ref-1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      66. ClaimResponse.request.type
      Definition

      The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

      The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

      ShortType the reference refers to (e.g. "Patient")
      Comments

      This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

      Control0..1
      BindingUnless not suitable, these codes SHALL be taken from ResourceType
      (extensible to http://hl7.org/fhir/ValueSet/resource-types)

      Aa resource (or, for logical models, the URI of the logical model).

      Typeuri
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      68. ClaimResponse.request.identifier
      Definition

      An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

      ShortLogical reference, when literal reference is not known
      Comments

      When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

      When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

      Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

      Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..1
      TypeIdentifier
      Is Modifierfalse
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      70. ClaimResponse.request.display
      Definition

      Plain text narrative that identifies the resource in addition to the resource reference.

      ShortText alternative for the resource
      Comments

      This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      72. ClaimResponse.outcome
      Definition

      The outcome of the claim, predetermination, or preauthorization processing.

      Shortqueued | complete | error | partial
      Comments

      The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

      Control1..1
      BindingThe codes SHALL be taken from ClaimProcessingCodes
      (required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

      The result of the claim processing.

      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Requirements

      To advise the requestor of an overall processing outcome.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      74. ClaimResponse.disposition
      Definition

      A human readable description of the status of the adjudication.

      ShortDisposition Message
      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Requirements

      Provided for user display.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      76. ClaimResponse.preAuthRef
      Definition

      Reference from the Insurer which is used in later communications which refers to this adjudication.

      ShortPreauthorization reference
      Comments

      This value is only present on preauthorization adjudications.

      Control0..1
      Typestring
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summaryfalse
      Requirements

      On subsequent claims, the insurer may require the provider to quote this value.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      78. ClaimResponse.preAuthPeriod
      Definition

      The time frame during which this authorization is effective.

      ShortPreauthorization reference effective period
      Control0..1
      TypePeriod
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      80. ClaimResponse.payeeType
      Definition

      Type of Party to be reimbursed: subscriber, provider, other.

      ShortParty to be paid any benefits payable
      Control0..1
      BindingFor example codes, see Claim Payee Type Codes
      (example to http://hl7.org/fhir/ValueSet/payeetype)

      A code for the party to be reimbursed.

      TypeCodeableConcept
      Is Modifierfalse
      Summaryfalse
      Requirements

      Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      82. ClaimResponse.item
      Definition

      A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

      ShortAdjudication for claim line items
      Control0..*
      TypeBackboneElement
      Is Modifierfalse
      Must Supporttrue
      Summaryfalse
      Requirements

      The adjudication for items provided on the claim.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      84. ClaimResponse.item.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      86. ClaimResponse.item.extension
      Definition

      An Extension

      ShortExtension
      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on ClaimResponse.item.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 88. ClaimResponse.item.extension:itemTraceNumber
        Slice NameitemTraceNumber
        Definition

        Uniquely identifies this claim item. (2000F-TRN)

        ShortUniquely identifies this claim item. (2000F-TRN)
        Control0..*
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        90. ClaimResponse.item.extension:preAuthIssueDate
        Slice NamepreAuthIssueDate
        Definition

        The date when this item's preauthorization was issued.

        ShortThe date when this item's preauthorization was issued.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        92. ClaimResponse.item.extension:preAuthPeriod
        Slice NamepreAuthPeriod
        Definition

        The date/period when this item's preauthorization is valid.

        ShortThe date/period when this item's preauthorization is valid.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        94. ClaimResponse.item.extension:previousAuthorizationNumber
        Slice NamepreviousAuthorizationNumber
        Definition

        A string assigned by the UMO to an authorized review outcome associated with this service item.

        ShortA string assigned by the UMO to an authorized review outcome associated with this service item.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(AuthorizationNumber) (Extension Type: string)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        96. ClaimResponse.item.extension:administrationReferenceNumber
        Slice NameadministrationReferenceNumber
        Definition

        A string assigned by the UMO to the original disallowed review outcome associated with this service item.

        ShortA string assigned by the UMO to the original disallowed review outcome associated with this service item.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        98. ClaimResponse.item.extension:requestedServiceDate
        Slice NamerequestedServiceDate
        Definition

        The original date/period that was requested by the submitter for this item.

        ShortThe original date/period that was requested by the submitter for this item.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemRequestedServiceDate) (Extension Type: Choice of: dateTime, Period)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        100. ClaimResponse.item.extension:authorizedProvider
        Slice NameauthorizedProvider
        Definition

        The specific provider who has been authorized to provide this item.

        ShortThe specific provider who has been authorized to provide this item.
        Control0..*
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemAuthorizedProvider) (Complex Extension)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        102. ClaimResponse.item.extension:authorizedItemDetail
        Slice NameauthorizedItemDetail
        Definition

        The details of what has been authorized for this item.

        ShortThe details of what has been authorized for this item.
        Control0..1
        This element is affected by the following invariants: ele-1
        TypeExtension(ItemAuthorizedDetail) (Complex Extension)
        Is Modifierfalse
        Must Supporttrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        104. ClaimResponse.item.extension:communicatedDiagnosis
        Slice NamecommunicatedDiagnosis
        Definition

        A code representing the diagnosis that is the subject of the communication

        ShortA code representing the diagnosis that is relevant to the preauthorization.
        Control0..*
        TypeExtension(CommunicatedDiagnosis) (Extension Type: CodeableConcept)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        106. ClaimResponse.item.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        108. ClaimResponse.item.itemSequence
        Definition

        A number to uniquely reference the claim item entries.

        ShortSequence numbers SHALL stay the same across all instances of the Prior Authorization, eg the Claim, ClaimResponse, ClaimUpdate, ClaimUpdateResponse
        Comments

        Each item returned on the PAS ClaimResponse SHALL echo the same item sequence number as that same item had on the Claim. The item.sequence element SHALL serve as the main tracing identifier of items throughout requests and responses.

        Control1..1
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summaryfalse
        Requirements

        Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        110. ClaimResponse.item.noteNumber
        Definition

        The numbers associated with notes below which apply to the adjudication of this item.

        ShortApplicable note numbers
        Control0..*
        TypepositiveInt
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summaryfalse
        Requirements

        Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        112. ClaimResponse.item.adjudication
        Definition

        If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

        ShortAdjudication details
        Control1..*
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Requirements

        The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        114. ClaimResponse.item.adjudication.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        116. ClaimResponse.item.adjudication.extension
        Definition

        An Extension

        ShortExtension
        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on ClaimResponse.item.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 118. ClaimResponse.item.adjudication.extension:reviewAction
          Slice NamereviewAction
          Definition

          The details of the review action that is necessary for the authorization.

          ShortThe details of the review action that is necessary for the authorization.
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(ReviewAction) (Complex Extension)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          120. ClaimResponse.item.adjudication.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          122. ClaimResponse.item.adjudication.category
          Definition

          A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

          ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
          Comments

          For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

          Control1..1
          BindingFor example codes, see AdjudicationValueCodes
          (example to http://hl7.org/fhir/ValueSet/adjudication)

          The adjudication codes.

          TypeCodeableConcept
          Is Modifierfalse
          Summaryfalse
          Requirements

          Needed to enable understanding of the context of the other information in the adjudication.

          Pattern Value{
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
              "code" : "submitted"
            }]
          }
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          124. ClaimResponse.item.adjudication.reason
          Definition

          A code supporting the understanding of the adjudication result and explaining variance from expected amount.

          ShortExplanation of adjudication outcome
          Comments

          For example may indicate that the funds for this benefit type have been exhausted.

          Control0..1
          BindingFor example codes, see AdjudicationReasonCodes
          (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

          The adjudication reason codes.

          TypeCodeableConcept
          Is Modifierfalse
          Summaryfalse
          Requirements

          To support understanding of variance from adjudication expectations.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          126. ClaimResponse.item.adjudication.amount
          Definition

          Monetary amount associated with the category.

          ShortMonetary amount
          Comments

          For example: amount submitted, eligible amount, co-payment, and benefit payable.

          Control0..1
          TypeMoney
          Is Modifierfalse
          Summaryfalse
          Requirements

          Most adjuciation categories convey a monetary amount.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          128. ClaimResponse.item.adjudication.value
          Definition

          A non-monetary value associated with the category. Mutually exclusive to the amount element above.

          ShortNon-monetary value
          Comments

          For example: eligible percentage or co-payment percentage.

          Control0..1
          Typedecimal
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Some adjudication categories convey a percentage or a fixed value.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          130. ClaimResponse.item.detail
          Definition

          A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

          ShortAdjudication for claim details
          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          The adjudication for details provided on the claim.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          132. ClaimResponse.item.detail.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          134. ClaimResponse.item.detail.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          136. ClaimResponse.item.detail.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          138. ClaimResponse.item.detail.detailSequence
          Definition

          A number to uniquely reference the claim detail entry.

          ShortClaim detail instance identifier
          Control1..1
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          140. ClaimResponse.item.detail.noteNumber
          Definition

          The numbers associated with notes below which apply to the adjudication of this item.

          ShortApplicable note numbers
          Control0..*
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          142. ClaimResponse.item.detail.adjudication
          Definition

          The adjudication results.

          ShortDetail level adjudication details
          Control1..*
          TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          144. ClaimResponse.item.detail.subDetail
          Definition

          A sub-detail adjudication of a simple product or service.

          ShortAdjudication for claim sub-details
          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Summaryfalse
          Requirements

          The adjudication for sub-details provided on the claim.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          146. ClaimResponse.item.detail.subDetail.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          148. ClaimResponse.item.detail.subDetail.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          150. ClaimResponse.item.detail.subDetail.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored even if unrecognized
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
          Summarytrue
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content, modifiers
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          152. ClaimResponse.item.detail.subDetail.subDetailSequence
          Definition

          A number to uniquely reference the claim sub-detail entry.

          ShortClaim sub-detail instance identifier
          Control1..1
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          154. ClaimResponse.item.detail.subDetail.noteNumber
          Definition

          The numbers associated with notes below which apply to the adjudication of this item.

          ShortApplicable note numbers
          Control0..*
          TypepositiveInt
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summaryfalse
          Requirements

          Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          156. ClaimResponse.item.detail.subDetail.adjudication
          Definition

          The adjudication results.

          ShortSubdetail level adjudication details
          Control0..*
          TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          158. ClaimResponse.addItem
          Definition

          The first-tier service adjudications for payor added product or service lines.

          ShortInsurer added line items
          Control0..*
          TypeBackboneElement
          Is Modifierfalse
          Must Supporttrue
          Summaryfalse
          Requirements

          Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          160. ClaimResponse.addItem.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          162. ClaimResponse.addItem.extension
          Definition

          An Extension

          ShortExtension
          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on ClaimResponse.addItem.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 164. ClaimResponse.addItem.extension:itemTraceNumber
            Slice NameitemTraceNumber
            Definition

            Uniquely identifies this claim item. (2000F-TRN)

            ShortExtension
            Control0..*
            This element is affected by the following invariants: ele-1
            TypeExtension(ItemTraceNumber) (Extension Type: Identifier(PAS Identifier))
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            166. ClaimResponse.addItem.extension:preAuthIssueDate
            Slice NamepreAuthIssueDate
            Definition

            The date when this item's preauthorization was issued.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(ItemPreAuthIssueDate) (Extension Type: date)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            168. ClaimResponse.addItem.extension:preAuthPeriod
            Slice NamepreAuthPeriod
            Definition

            The date/period when this item's preauthorization is valid.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(ItemPreAuthPeriod) (Extension Type: Period)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            170. ClaimResponse.addItem.extension:previousAuthorizationNumber
            Slice NamepreviousAuthorizationNumber
            Definition

            A string assigned by the UMO to an authorized review outcome associated with this service item.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(AuthorizationNumber) (Extension Type: string)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            172. ClaimResponse.addItem.extension:administrationReferenceNumber
            Slice NameadministrationReferenceNumber
            Definition

            A string assigned by the UMO to the original disallowed review outcome associated with this service item.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(AdministrationReferenceNumber) (Extension Type: string)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            174. ClaimResponse.addItem.extension:epsdtIndicator
            Slice NameepsdtIndicator
            Definition

            An indicator of whether early and periodic screen for diagnosis and treatment of children is involved.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(EPSDTIndicator) (Extension Type: boolean)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            176. ClaimResponse.addItem.extension:nursingHomeResidentialStatus
            Slice NamenursingHomeResidentialStatus
            Definition

            A code specifying the status of a nursing home resident at the time of service. (SV209)

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(NursingHomeResidentialStatus) (Extension Type: CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            178. ClaimResponse.addItem.extension:nursingHomeLevelOfCare
            Slice NamenursingHomeLevelOfCare
            Definition

            A code specifying the level of care provided by a nursing home facility. (SV120, SV210)

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(NursingHomeLevelOfCare) (Extension Type: CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            180. ClaimResponse.addItem.extension:productOrServiceCodeEnd
            Slice NameproductOrServiceCodeEnd
            Definition

            Used to provide the last code in a series of codes for the service being requested.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(ProductOrServiceCodeEnd) (Extension Type: CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            182. ClaimResponse.addItem.extension:revenue
            Slice Namerevenue
            Definition

            A revenue code that expresses what was approved which maps to X12 SV201

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(RevenueCode) (Extension Type: CodeableConcept)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            184. ClaimResponse.addItem.extension:revenueUnitRateLimit
            Slice NamerevenueUnitRateLimit
            Definition

            The limit on the rate per unit of revenue for hospital accomodation. (SV206)

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(RevenueUnitRateLimit) (Extension Type: decimal)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            186. ClaimResponse.addItem.extension:requestedService
            Slice NamerequestedService
            Definition

            The details of the service being requested.

            ShortExtension
            Control0..1
            This element is affected by the following invariants: ele-1
            TypeExtension(RequestedService) (Extension Type: Reference(PAS Medication Request, PAS Service Request, PAS Device Request, PAS Nutrition Order))
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            188. ClaimResponse.addItem.modifierExtension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

            ShortExtensions that cannot be ignored even if unrecognized
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            Requirements

            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

            Alternate Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            190. ClaimResponse.addItem.itemSequence
            Definition

            Claim items which this service line is intended to replace.

            ShortItem sequence number
            Control1..1
            TypepositiveInt
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summaryfalse
            Requirements

            Provides references to the claim items.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            192. ClaimResponse.addItem.detailSequence
            Definition

            The sequence number of the details within the claim item which this line is intended to replace.

            ShortDetail sequence number
            Control0..*
            TypepositiveInt
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summaryfalse
            Requirements

            Provides references to the claim details within the claim item.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            194. ClaimResponse.addItem.subdetailSequence
            Definition

            The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

            ShortSubdetail sequence number
            Control0..*
            TypepositiveInt
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summaryfalse
            Requirements

            Provides references to the claim sub-details within the claim detail.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            196. ClaimResponse.addItem.provider
            Definition

            The providers who are authorized for the services rendered to the patient.

            ShortAuthorized providers
            Control0..*
            TypeReference(PAS Practitioner, PAS Organization Base Profile)
            Is Modifierfalse
            Must Supporttrue
            Must Support TypesNo must-support rules about the choice of types/profiles
            Summaryfalse
            Requirements

            Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            198. ClaimResponse.addItem.provider.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            200. ClaimResponse.addItem.provider.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on ClaimResponse.addItem.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 202. ClaimResponse.addItem.provider.extension:providerType
              Slice NameproviderType
              Definition

              The type of provider who has been authorized to provide this item.

              ShortExtension
              Control0..1
              TypeExtension(AuthorizedProviderType) (Extension Type: CodeableConcept)
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              204. ClaimResponse.addItem.provider.reference
              Definition

              A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

              ShortLiteral reference, Relative, internal or absolute URL
              Comments

              Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

              Control0..1
              This element is affected by the following invariants: ref-1
              Typestring
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              206. ClaimResponse.addItem.provider.type
              Definition

              The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

              The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

              ShortType the reference refers to (e.g. "Patient")
              Comments

              This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

              Control0..1
              BindingUnless not suitable, these codes SHALL be taken from ResourceType
              (extensible to http://hl7.org/fhir/ValueSet/resource-types)

              Aa resource (or, for logical models, the URI of the logical model).

              Typeuri
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              208. ClaimResponse.addItem.provider.identifier
              Definition

              An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

              ShortLogical reference, when literal reference is not known
              Comments

              When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

              When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

              Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

              Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

              NoteThis is a business identifier, not a resource identifier (see discussion)
              Control0..1
              TypeIdentifier
              Is Modifierfalse
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              210. ClaimResponse.addItem.provider.display
              Definition

              Plain text narrative that identifies the resource in addition to the resource reference.

              ShortText alternative for the resource
              Comments

              This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

              Control0..1
              Typestring
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              212. ClaimResponse.addItem.productOrService
              Definition

              When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

              ShortBilling, service, product, or drug code
              Comments

              If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

              Control1..1
              BindingThe codes SHALL be taken from X12 278 Requested Service Type
              (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceType)
              TypeCodeableConcept
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              Necessary to state what was provided or done.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              214. ClaimResponse.addItem.modifier
              Definition

              Item typification or modifiers codes to convey additional context for the product or service.

              ShortService/Product billing modifiers
              Comments

              For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

              Control0..*
              BindingThe codes SHALL be taken from X12 278 Requested Service Modifier Type
              (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RequestedServiceModifierType)
              TypeCodeableConcept
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              To support inclusion of the item for adjudication or to charge an elevated fee.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              216. ClaimResponse.addItem.programCode
              Definition

              Identifies the program under which this may be recovered.

              ShortProgram the product or service is provided under
              Comments

              For example: Neonatal program, child dental program or drug users recovery program.

              Control0..*
              BindingFor example codes, see ExampleProgramReasonCodes
              (example to http://hl7.org/fhir/ValueSet/ex-program-code)

              Program specific reason codes.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              218. ClaimResponse.addItem.serviced[x]
              Definition

              The date or dates when the service or product was supplied, performed or completed.

              ShortDate or dates of service or product delivery
              Control0..1
              TypeChoice of: date, Period
              [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Must Support TypesNo must-support rules about the choice of types/profiles
              Summaryfalse
              Requirements

              Needed to determine whether the service or product was provided during the term of the insurance coverage.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              220. ClaimResponse.addItem.location[x]
              Definition

              Where the product or service was provided.

              ShortPlace of service or where product was supplied
              Control0..1
              BindingFor example codes, see ExampleServicePlaceCodes
              (example to http://hl7.org/fhir/ValueSet/service-place)

              Place of service: pharmacy, school, prison, etc.

              TypeChoice of: CodeableConcept, Address, Reference(Location)
              [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
              Is Modifierfalse
              Must Supporttrue
              Must Support TypesNo must-support rules about the choice of types/profiles
              Summaryfalse
              Requirements

              The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              222. ClaimResponse.addItem.quantity
              Definition

              The number of repetitions of a service or product.

              ShortCount of products or services
              Control0..1
              TypeQuantity(PAS Quantity)
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              Required when the product or service code does not convey the quantity provided.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              224. ClaimResponse.addItem.unitPrice
              Definition

              If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

              ShortFee, charge or cost per item
              Control0..1
              TypeMoney
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Requirements

              The amount charged to the patient by the provider for a single unit.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              226. ClaimResponse.addItem.factor
              Definition

              A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

              ShortPrice scaling factor
              Comments

              To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

              Control0..1
              Typedecimal
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              228. ClaimResponse.addItem.net
              Definition

              The quantity times the unit price for an additional service or product or charge.

              ShortTotal item cost
              Comments

              For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

              Control0..1
              TypeMoney
              Is Modifierfalse
              Summaryfalse
              Requirements

              Provides the total amount claimed for the group (if a grouper) or the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              230. ClaimResponse.addItem.bodySite
              Definition

              Physical service site on the patient (limb, tooth, etc.).

              ShortAnatomical location
              Comments

              For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

              Control0..1
              BindingFor example codes, see OralSiteCodes
              (example to http://hl7.org/fhir/ValueSet/tooth)

              The code for the teeth, quadrant, sextant and arch.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Allows insurer to validate specific procedures.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              232. ClaimResponse.addItem.subSite
              Definition

              A region or surface of the bodySite, e.g. limb region or tooth surface(s).

              ShortAnatomical sub-location
              Control0..*
              BindingFor example codes, see SurfaceCodes
              (example to http://hl7.org/fhir/ValueSet/surface)

              The code for the tooth surface and surface combinations.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              Allows insurer to validate specific procedures.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              234. ClaimResponse.addItem.noteNumber
              Definition

              The numbers associated with notes below which apply to the adjudication of this item.

              ShortApplicable note numbers
              Control0..*
              TypepositiveInt
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summaryfalse
              Requirements

              Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              236. ClaimResponse.addItem.adjudication
              Definition

              The adjudication results.

              ShortAdded items adjudication
              Control1..*
              TypeBackboneElement
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              238. ClaimResponse.addItem.adjudication.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              240. ClaimResponse.addItem.adjudication.extension
              Definition

              An Extension

              ShortExtension
              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              SlicingThis element introduces a set of slices on ClaimResponse.addItem.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 242. ClaimResponse.addItem.adjudication.extension:reviewAction
                Slice NamereviewAction
                Definition

                The details of the review action that is necessary for the authorization.

                ShortThe details of the review action that is necessary for the authorization.
                Control0..1
                This element is affected by the following invariants: ele-1
                TypeExtension(ReviewAction) (Complex Extension)
                Is Modifierfalse
                Must Supporttrue
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                244. ClaimResponse.addItem.adjudication.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                246. ClaimResponse.addItem.adjudication.category
                Definition

                A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

                ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
                Comments

                For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                Control1..1
                BindingFor example codes, see AdjudicationValueCodes
                (example to http://hl7.org/fhir/ValueSet/adjudication)

                The adjudication codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Needed to enable understanding of the context of the other information in the adjudication.

                Pattern Value{
                  "coding" : [{
                    "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                    "code" : "submitted"
                  }]
                }
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                248. ClaimResponse.addItem.adjudication.reason
                Definition

                A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                ShortExplanation of adjudication outcome
                Comments

                For example may indicate that the funds for this benefit type have been exhausted.

                Control0..1
                BindingFor example codes, see AdjudicationReasonCodes
                (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                The adjudication reason codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                To support understanding of variance from adjudication expectations.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                250. ClaimResponse.addItem.adjudication.amount
                Definition

                Monetary amount associated with the category.

                ShortMonetary amount
                Comments

                For example: amount submitted, eligible amount, co-payment, and benefit payable.

                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                Most adjuciation categories convey a monetary amount.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                252. ClaimResponse.addItem.adjudication.value
                Definition

                A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                ShortNon-monetary value
                Comments

                For example: eligible percentage or co-payment percentage.

                Control0..1
                Typedecimal
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Some adjudication categories convey a percentage or a fixed value.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                254. ClaimResponse.addItem.detail
                Definition

                The second-tier service adjudications for payor added services.

                ShortInsurer added line details
                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                256. ClaimResponse.addItem.detail.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                258. ClaimResponse.addItem.detail.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                260. ClaimResponse.addItem.detail.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                262. ClaimResponse.addItem.detail.productOrService
                Definition

                When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                ShortBilling, service, product, or drug code
                Comments

                If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                Control1..1
                BindingFor example codes, see USCLSCodes
                (example to http://hl7.org/fhir/ValueSet/service-uscls)

                Allowable service and product codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Necessary to state what was provided or done.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                264. ClaimResponse.addItem.detail.modifier
                Definition

                Item typification or modifiers codes to convey additional context for the product or service.

                ShortService/Product billing modifiers
                Comments

                For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

                Control0..*
                BindingFor example codes, see ModifierTypeCodes
                (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                To support inclusion of the item for adjudication or to charge an elevated fee.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                266. ClaimResponse.addItem.detail.quantity
                Definition

                The number of repetitions of a service or product.

                ShortCount of products or services
                Control0..1
                TypeQuantity(SimpleQuantity)
                Is Modifierfalse
                Summaryfalse
                Requirements

                Required when the product or service code does not convey the quantity provided.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                268. ClaimResponse.addItem.detail.unitPrice
                Definition

                If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                ShortFee, charge or cost per item
                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                The amount charged to the patient by the provider for a single unit.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                270. ClaimResponse.addItem.detail.factor
                Definition

                A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                ShortPrice scaling factor
                Comments

                To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                Control0..1
                Typedecimal
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                272. ClaimResponse.addItem.detail.net
                Definition

                The quantity times the unit price for an additional service or product or charge.

                ShortTotal item cost
                Comments

                For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                Provides the total amount claimed for the group (if a grouper) or the line item.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                274. ClaimResponse.addItem.detail.noteNumber
                Definition

                The numbers associated with notes below which apply to the adjudication of this item.

                ShortApplicable note numbers
                Control0..*
                TypepositiveInt
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                276. ClaimResponse.addItem.detail.adjudication
                Definition

                The adjudication results.

                ShortAdded items detail adjudication
                Control1..*
                TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                278. ClaimResponse.addItem.detail.subDetail
                Definition

                The third-tier service adjudications for payor added services.

                ShortInsurer added line items
                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                280. ClaimResponse.addItem.detail.subDetail.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                282. ClaimResponse.addItem.detail.subDetail.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                284. ClaimResponse.addItem.detail.subDetail.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                286. ClaimResponse.addItem.detail.subDetail.productOrService
                Definition

                When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                ShortBilling, service, product, or drug code
                Comments

                If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                Control1..1
                BindingFor example codes, see USCLSCodes
                (example to http://hl7.org/fhir/ValueSet/service-uscls)

                Allowable service and product codes.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Necessary to state what was provided or done.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                288. ClaimResponse.addItem.detail.subDetail.modifier
                Definition

                Item typification or modifiers codes to convey additional context for the product or service.

                ShortService/Product billing modifiers
                Comments

                For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

                Control0..*
                BindingFor example codes, see ModifierTypeCodes
                (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                To support inclusion of the item for adjudication or to charge an elevated fee.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                290. ClaimResponse.addItem.detail.subDetail.quantity
                Definition

                The number of repetitions of a service or product.

                ShortCount of products or services
                Control0..1
                TypeQuantity(SimpleQuantity)
                Is Modifierfalse
                Summaryfalse
                Requirements

                Required when the product or service code does not convey the quantity provided.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                292. ClaimResponse.addItem.detail.subDetail.unitPrice
                Definition

                If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                ShortFee, charge or cost per item
                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                The amount charged to the patient by the provider for a single unit.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                294. ClaimResponse.addItem.detail.subDetail.factor
                Definition

                A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                ShortPrice scaling factor
                Comments

                To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                Control0..1
                Typedecimal
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                296. ClaimResponse.addItem.detail.subDetail.net
                Definition

                The quantity times the unit price for an additional service or product or charge.

                ShortTotal item cost
                Comments

                For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                Control0..1
                TypeMoney
                Is Modifierfalse
                Summaryfalse
                Requirements

                Provides the total amount claimed for the group (if a grouper) or the line item.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                298. ClaimResponse.addItem.detail.subDetail.noteNumber
                Definition

                The numbers associated with notes below which apply to the adjudication of this item.

                ShortApplicable note numbers
                Control0..*
                TypepositiveInt
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summaryfalse
                Requirements

                Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                300. ClaimResponse.addItem.detail.subDetail.adjudication
                Definition

                The adjudication results.

                ShortAdded items detail adjudication
                Control1..*
                TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                302. ClaimResponse.adjudication
                Definition

                The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

                ShortHeader-level adjudication
                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Must Supporttrue
                Summaryfalse
                Requirements

                Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                304. ClaimResponse.adjudication.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                306. ClaimResponse.adjudication.extension
                Definition

                An Extension

                ShortExtension
                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                SlicingThis element introduces a set of slices on ClaimResponse.adjudication.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 308. ClaimResponse.adjudication.extension:reviewAction
                  Slice NamereviewAction
                  Definition

                  The details of the review action that is necessary for the authorization.

                  ShortThe details of the review action that is necessary for the authorization.
                  Control0..1
                  This element is affected by the following invariants: ele-1
                  TypeExtension(ReviewAction) (Complex Extension)
                  Is Modifierfalse
                  Must Supporttrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  310. ClaimResponse.adjudication.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  312. ClaimResponse.adjudication.category
                  Definition

                  A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.

                  ShortThis code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
                  Comments

                  For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                  Control1..1
                  BindingFor example codes, see AdjudicationValueCodes
                  (example to http://hl7.org/fhir/ValueSet/adjudication)

                  The adjudication codes.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to enable understanding of the context of the other information in the adjudication.

                  Pattern Value{
                    "coding" : [{
                      "system" : "http://terminology.hl7.org/CodeSystem/adjudication",
                      "code" : "submitted"
                    }]
                  }
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  314. ClaimResponse.adjudication.reason
                  Definition

                  A code supporting the understanding of the adjudication result and explaining variance from expected amount.

                  ShortExplanation of adjudication outcome
                  Comments

                  For example may indicate that the funds for this benefit type have been exhausted.

                  Control0..1
                  BindingFor example codes, see AdjudicationReasonCodes
                  (example to http://hl7.org/fhir/ValueSet/adjudication-reason)

                  The adjudication reason codes.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  To support understanding of variance from adjudication expectations.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  316. ClaimResponse.adjudication.amount
                  Definition

                  Monetary amount associated with the category.

                  ShortMonetary amount
                  Comments

                  For example: amount submitted, eligible amount, co-payment, and benefit payable.

                  Control0..1
                  TypeMoney
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Most adjuciation categories convey a monetary amount.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  318. ClaimResponse.adjudication.value
                  Definition

                  A non-monetary value associated with the category. Mutually exclusive to the amount element above.

                  ShortNon-monetary value
                  Comments

                  For example: eligible percentage or co-payment percentage.

                  Control0..1
                  Typedecimal
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  Some adjudication categories convey a percentage or a fixed value.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  320. ClaimResponse.total
                  Definition

                  Categorized monetary totals for the adjudication.

                  ShortAdjudication totals
                  Comments

                  Totals for amounts submitted, co-pays, benefits payable etc.

                  Control0..*
                  TypeBackboneElement
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  To provide the requestor with financial totals by category for the adjudication.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  322. ClaimResponse.total.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  324. ClaimResponse.total.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  326. ClaimResponse.total.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  328. ClaimResponse.total.category
                  Definition

                  A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.

                  ShortType of adjudication information
                  Comments

                  For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

                  Control1..1
                  BindingFor example codes, see AdjudicationValueCodes
                  (example to http://hl7.org/fhir/ValueSet/adjudication)

                  The adjudication codes.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  Needed to convey the type of total provided.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  330. ClaimResponse.total.amount
                  Definition

                  Monetary total amount associated with the category.

                  ShortFinancial total for the category
                  Control1..1
                  TypeMoney
                  Is Modifierfalse
                  Summarytrue
                  Requirements

                  Needed to convey the total monetary amount.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  332. ClaimResponse.payment
                  Definition

                  Payment details for the adjudication of the claim.

                  ShortPayment Details
                  Control0..1
                  TypeBackboneElement
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to convey references to the financial instrument that has been used if payment has been made.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  334. ClaimResponse.payment.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  336. ClaimResponse.payment.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  338. ClaimResponse.payment.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  340. ClaimResponse.payment.type
                  Definition

                  Whether this represents partial or complete payment of the benefits payable.

                  ShortPartial or complete payment
                  Control1..1
                  BindingFor example codes, see ExamplePaymentTypeCodes
                  (example to http://hl7.org/fhir/ValueSet/ex-paymenttype)

                  The type (partial, complete) of the payment.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  To advise the requestor when the insurer believes all payments to have been completed.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  342. ClaimResponse.payment.adjustment
                  Definition

                  Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

                  ShortPayment adjustment for non-claim issues
                  Comments

                  Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.

                  Control0..1
                  TypeMoney
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  To advise the requestor of adjustments applied to the payment.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  344. ClaimResponse.payment.adjustmentReason
                  Definition

                  Reason for the payment adjustment.

                  ShortExplanation for the adjustment
                  Control0..1
                  BindingFor example codes, see PaymentAdjustmentReasonCodes
                  (example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason)

                  Payment Adjustment reason codes.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to clarify the monetary adjustment.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  346. ClaimResponse.payment.date
                  Definition

                  Estimated date the payment will be issued or the actual issue date of payment.

                  ShortExpected date of payment
                  Control0..1
                  Typedate
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  To advise the payee when payment can be expected.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  348. ClaimResponse.payment.amount
                  Definition

                  Benefits payable less any payment adjustment.

                  ShortPayable amount after adjustment
                  Control1..1
                  TypeMoney
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to provide the actual payment amount.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  350. ClaimResponse.payment.identifier
                  Definition

                  Issuer's unique identifier for the payment instrument.

                  ShortBusiness identifier for the payment
                  Comments

                  For example: EFT number or check number.

                  NoteThis is a business identifier, not a resource identifier (see discussion)
                  Control0..1
                  TypeIdentifier
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Enable the receiver to reconcile when payment received.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  352. ClaimResponse.fundsReserve
                  Definition

                  A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

                  ShortFunds reserved status
                  Comments

                  Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

                  Control0..1
                  BindingFor example codes, see Funds Reservation Codes
                  (example to http://hl7.org/fhir/ValueSet/fundsreserve)

                  For whom funds are to be reserved: (Patient, Provider, None).

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  354. ClaimResponse.formCode
                  Definition

                  A code for the form to be used for printing the content.

                  ShortPrinted form identifier
                  Comments

                  May be needed to identify specific jurisdictional forms.

                  Control0..1
                  BindingFor example codes, see Form Codes
                  (example to http://hl7.org/fhir/ValueSet/forms)

                  The forms codes.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to specify the specific form used for producing output for this response.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  356. ClaimResponse.form
                  Definition

                  The actual form, by reference or inclusion, for printing the content or an EOB.

                  ShortPrinted reference or actual form
                  Comments

                  Needed to permit insurers to include the actual form.

                  Control0..1
                  TypeAttachment
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Needed to include the specific form used for producing output for this response.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  358. ClaimResponse.processNote
                  Definition

                  A note that describes or explains adjudication results in a human readable form.

                  ShortNote concerning adjudication
                  Control0..*
                  TypeBackboneElement
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Provides the insurer specific textual explanations associated with the processing.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  360. ClaimResponse.processNote.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  362. ClaimResponse.processNote.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  364. ClaimResponse.processNote.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  366. ClaimResponse.processNote.number
                  Definition

                  A number to uniquely identify a note entry.

                  ShortNote instance identifier
                  Control1..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Necessary to provide a mechanism to link from adjudications.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  368. ClaimResponse.processNote.type
                  Definition

                  The business purpose of the note text.

                  Shortdisplay | print | printoper
                  Control0..1
                  BindingThe codes SHALL be taken from NoteType
                  (required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)

                  The presentation types of notes.

                  Typecode
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  To convey the expectation for when the text is used.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  370. ClaimResponse.processNote.text
                  Definition

                  The explanation or description associated with the processing.

                  ShortNote explanatory text
                  Control1..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Required to provide human readable explanation.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  372. ClaimResponse.processNote.language
                  Definition

                  A code to define the language used in the text of the note.

                  ShortLanguage of the text
                  Comments

                  Only required if the language is different from the resource language.

                  Control0..1
                  BindingThe codes SHOULD be taken from CommonLanguages
                  (preferred to http://hl7.org/fhir/ValueSet/languages)

                  A human language.

                  Additional BindingsPurpose
                  AllLanguagesMax Binding
                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Note text may vary from the resource defined language.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  374. ClaimResponse.communicationRequest
                  Definition

                  Request for additional supporting or authorizing information.

                  ShortRequest for additional information
                  Comments

                  For example: professional reports, documents, images, clinical resources, or accident reports.

                  Control0..*
                  TypeReference(PAS CommunicationRequest)
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Need to communicate insurer request for additional information required to support the adjudication.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  376. ClaimResponse.insurance
                  Definition

                  Financial instruments for reimbursement for the health care products and services specified on the claim.

                  ShortPatient insurance information
                  Comments

                  All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

                  Control0..*
                  TypeBackboneElement
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  At least one insurer is required for a claim to be a claim.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  378. ClaimResponse.insurance.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  380. ClaimResponse.insurance.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  382. ClaimResponse.insurance.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  384. ClaimResponse.insurance.sequence
                  Definition

                  A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

                  ShortInsurance instance identifier
                  Control1..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  To maintain order of the coverages.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  386. ClaimResponse.insurance.focal
                  Definition

                  A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

                  ShortCoverage to be used for adjudication
                  Comments

                  A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

                  Control1..1
                  Typeboolean
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  To identify which coverage in the list is being used to adjudicate this claim.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  388. ClaimResponse.insurance.coverage
                  Definition

                  Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

                  ShortInsurance information
                  Control1..1
                  TypeReference(Coverage)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Required to allow the adjudicator to locate the correct policy and history within their information system.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  390. ClaimResponse.insurance.businessArrangement
                  Definition

                  A business agreement number established between the provider and the insurer for special business processing purposes.

                  ShortAdditional provider contract number
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summaryfalse
                  Requirements

                  Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  392. ClaimResponse.insurance.claimResponse
                  Definition

                  The result of the adjudication of the line items for the Coverage specified in this insurance.

                  ShortAdjudication results
                  Comments

                  Must not be specified when 'focal=true' for this insurance.

                  Control0..1
                  TypeReference(ClaimResponse)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  394. ClaimResponse.error
                  Definition

                  Errors encountered during the processing of the adjudication.

                  ShortProcessing errors
                  Comments

                  If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

                  Control0..*
                  TypeBackboneElement
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Need to communicate processing issues to the requestor.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  396. ClaimResponse.error.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  398. ClaimResponse.error.extension
                  Definition

                  An Extension

                  ShortExtension
                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  SlicingThis element introduces a set of slices on ClaimResponse.error.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                  • value @ url
                  • 400. ClaimResponse.error.extension:followupAction
                    Slice NamefollowupAction
                    Definition

                    A code representing what action must occur to resolve this error.

                    ShortA code representing what action must occur to resolve this error.
                    Control0..1
                    This element is affected by the following invariants: ele-1
                    TypeExtension(ErrorFollowupAction) (Extension Type: CodeableConcept)
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    402. ClaimResponse.error.extension:errorElement
                    Slice NameerrorElement
                    Definition

                    The specific loop, segment, or element that this error information is about. The string will follow the X12 format for specifying elements and is returned from the Payer. Example: 2010A-NM103

                    ShortThe specific X12 loop, segment, or element that this error information is about.
                    Control0..1
                    This element is affected by the following invariants: ele-1
                    TypeExtension(ErrorElement) (Extension Type: string)
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    404. ClaimResponse.error.extension:errorPath
                    Slice NameerrorPath
                    Definition

                    The FHIRPath expression that indicates which FHIR element that this error information is about. The expression will start with the Bundle and can be followed to determine the specific element.

                    STU NOTE: We would like feedback during the STU period on whether this extension is sufficient for implementers to determine and display the errored element.

                    Examples: Bundle.entry[1].resource.name, Bundle.entry[0].resource.identifier[0].value

                    ShortThe FHIRPath expression that indicates which FHIR element that this error information is about.
                    Control0..1
                    This element is affected by the following invariants: ele-1
                    TypeExtension(ErrorPath) (Extension Type: string)
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    406. ClaimResponse.error.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    408. ClaimResponse.error.itemSequence
                    Definition

                    The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                    ShortItem sequence number
                    Control0..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Provides references to the claim items.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    410. ClaimResponse.error.detailSequence
                    Definition

                    The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                    ShortDetail sequence number
                    Control0..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Provides references to the claim details within the claim item.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    412. ClaimResponse.error.subDetailSequence
                    Definition

                    The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

                    ShortSubdetail sequence number
                    Control0..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Provides references to the claim sub-details within the claim detail.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    414. ClaimResponse.error.code
                    Definition

                    An error code, from a specified code system, which details why the claim could not be adjudicated.

                    ShortError code detailing processing issues
                    Control1..1
                    BindingThe codes SHALL be taken from X12 278 Reject Reason Value Set
                    (required to http://hl7.org/fhir/us/davinci-pas/ValueSet/X12278RejectReasonCodes)
                    TypeCodeableConcept
                    Is Modifierfalse
                    Must Supporttrue
                    Summaryfalse
                    Requirements

                    Required to convey processing errors.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))