This is the set of resources that conform to either of the profiles PAS Claim Response Base (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse-base) and PAS Claim Response Base (http://hl7.org/fhir/us/davinci-pas/StructureDefinition/profile-claimresponse-base). E.g. what you have to deal with if you get resources conforming to one of them
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | 0..* | Response to a preauthorization dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | ||
meta | Σ | 0..1 | Meta | Metadata about the resource ele-1: All FHIR elements must have a @value or children |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language. ele-1: All FHIR elements must have a @value or children | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation ele-1: All FHIR elements must have a @value or children | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
identifier | S | 0..* | ?? | An identifier intended for computation ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: ?? (required): Identifies the purpose for this identifier, if known . ele-1: All FHIR elements must have a @value or children |
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. ele-1: All FHIR elements must have a @value or children |
system | SΣ | 1..1 | uri | Should use a scheme of 'urn:trnorg:<TRN03>' ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/identifiers/patient |
value | SΣ | 1..1 | string | The value that is unique ele-1: All FHIR elements must have a @value or children Example General: 123456 |
period | Σ | 0..1 | Period | Time period when id is/was valid for use ele-1: All FHIR elements must have a @value or children |
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) ele-1: All FHIR elements must have a @value or children |
status | ?!SΣ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: ?? (required): A code specifying the state of the resource instance. ele-1: All FHIR elements must have a @value or children |
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ?? (extensible): The type or discipline-style of the claim. ele-1: All FHIR elements must have a @value or children |
subType | 0..1 | CodeableConcept | More granular claim type Binding: ?? (example): A more granular claim typecode. ele-1: All FHIR elements must have a @value or children | |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: ?? (required): Claim, preauthorization, predetermination. ele-1: All FHIR elements must have a @value or children |
patient | SΣ | 1..1 | Reference(PAS Beneficiary Patient | #sd-profile-beneficiary-profile-beneficiary) | The recipient of the products and services ele-1: All FHIR elements must have a @value or children |
created | SΣ | 1..1 | dateTime | Response creation date ele-1: All FHIR elements must have a @value or children |
insurer | SΣ | 1..1 | Reference(PAS Insurer Organization | #sd-profile-insurer-profile-insurer) | Party responsible for reimbursement ele-1: All FHIR elements must have a @value or children |
requestor | S | 0..1 | Reference(PAS Requestor Organization | PAS PractitionerRole | #sd-profile-requestor-profile-requestor) | Party responsible for the claim ele-1: All FHIR elements must have a @value or children |
request | SΣ | 1..1 | Reference(PAS Claim | #sd-profile-claim-profile-claim) | Id of resource triggering adjudication ele-1: All FHIR elements must have a @value or children |
outcome | SΣ | 1..1 | code | queued | complete | error | partial Binding: ?? (required): The result of the claim processing. ele-1: All FHIR elements must have a @value or children |
disposition | 0..1 | string | Disposition Message ele-1: All FHIR elements must have a @value or children | |
preAuthRef | 0..1 | string | Preauthorization reference ele-1: All FHIR elements must have a @value or children | |
preAuthPeriod | S | 0..1 | Period | Preauthorization reference effective period ele-1: All FHIR elements must have a @value or children |
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ?? (example): A code for the party to be reimbursed. ele-1: All FHIR elements must have a @value or children | |
item | S | 0..* | BackboneElement | Adjudication for claim line items ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
itemSequence | S | 1..1 | positiveInt | Claim item instance identifier ele-1: All FHIR elements must have a @value or children |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | S | 1..* | BackboneElement | Adjudication details ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. ele-1: All FHIR elements must have a @value or children | |
amount | 0..1 | Money | Monetary amount ele-1: All FHIR elements must have a @value or children | |
value | 0..1 | decimal | Non-monetary value ele-1: All FHIR elements must have a @value or children | |
detail | 0..* | BackboneElement | Adjudication for claim details ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
detailSequence | 1..1 | positiveInt | Claim detail instance identifier ele-1: All FHIR elements must have a @value or children | |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | 1..* | Detail level adjudication details ele-1: All FHIR elements must have a @value or children | ||
subDetail | 0..* | BackboneElement | Adjudication for claim sub-details ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier ele-1: All FHIR elements must have a @value or children | |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | 0..* | Subdetail level adjudication details ele-1: All FHIR elements must have a @value or children | ||
addItem | S | 0..* | BackboneElement | Insurer added line items ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
itemSequence | S | 1..1 | positiveInt | Item sequence number ele-1: All FHIR elements must have a @value or children |
detailSequence | 0..* | positiveInt | Detail sequence number ele-1: All FHIR elements must have a @value or children | |
subdetailSequence | 0..* | positiveInt | Subdetail sequence number ele-1: All FHIR elements must have a @value or children | |
provider | S | 0..* | Reference(PAS Practitioner | PAS Organization Base Profile | #sd-profile-practitioner-profile-practitioner) | Authorized providers ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). ele-1: All FHIR elements must have a @value or children |
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known ele-1: All FHIR elements must have a @value or children |
display | Σ | 0..1 | string | Text alternative for the resource ele-1: All FHIR elements must have a @value or children |
productOrService | S | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (required) ele-1: All FHIR elements must have a @value or children |
modifier | S | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (required) ele-1: All FHIR elements must have a @value or children |
programCode | 0..* | CodeableConcept | Program the product or service is provided under Binding: ?? (example): Program specific reason codes. ele-1: All FHIR elements must have a @value or children | |
serviced[x] | S | 0..1 | Date or dates of service or product delivery ele-1: All FHIR elements must have a @value or children | |
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | S | 0..1 | Place of service or where product was supplied Binding: ?? (example): Place of service: pharmacy, school, prison, etc. ele-1: All FHIR elements must have a @value or children | |
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | S | 0..1 | ?? | left: Count of products or services; right: A fixed quantity (no comparator) ele-1: All FHIR elements must have a @value or children |
unitPrice | S | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children |
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |
bodySite | 0..1 | CodeableConcept | Anatomical location Binding: ?? (example): The code for the teeth, quadrant, sextant and arch. ele-1: All FHIR elements must have a @value or children | |
subSite | 0..* | CodeableConcept | Anatomical sub-location Binding: ?? (example): The code for the tooth surface and surface combinations. ele-1: All FHIR elements must have a @value or children | |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | S | 1..* | BackboneElement | Added items adjudication ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. ele-1: All FHIR elements must have a @value or children | |
amount | 0..1 | Money | Monetary amount ele-1: All FHIR elements must have a @value or children | |
value | 0..1 | decimal | Non-monetary value ele-1: All FHIR elements must have a @value or children | |
detail | 0..* | BackboneElement | Insurer added line details ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. ele-1: All FHIR elements must have a @value or children | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ele-1: All FHIR elements must have a @value or children | |
quantity | 0..1 | ?? | Count of products or services ele-1: All FHIR elements must have a @value or children | |
unitPrice | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children | |
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | 1..* | Added items detail adjudication ele-1: All FHIR elements must have a @value or children | ||
subDetail | 0..* | BackboneElement | Insurer added line items ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
productOrService | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: ?? (example): Allowable service and product codes. ele-1: All FHIR elements must have a @value or children | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ?? (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. ele-1: All FHIR elements must have a @value or children | |
quantity | 0..1 | ?? | Count of products or services ele-1: All FHIR elements must have a @value or children | |
unitPrice | 0..1 | Money | Fee, charge or cost per item ele-1: All FHIR elements must have a @value or children | |
factor | 0..1 | decimal | Price scaling factor ele-1: All FHIR elements must have a @value or children | |
net | 0..1 | Money | Total item cost ele-1: All FHIR elements must have a @value or children | |
noteNumber | 0..* | positiveInt | Applicable note numbers ele-1: All FHIR elements must have a @value or children | |
adjudication | 1..* | Added items detail adjudication ele-1: All FHIR elements must have a @value or children | ||
adjudication | S | 0..* | BackboneElement | Header-level adjudication ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
category | 1..1 | CodeableConcept | This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted. Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: submitted | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: ?? (example): The adjudication reason codes. ele-1: All FHIR elements must have a @value or children | |
amount | 0..1 | Money | Monetary amount ele-1: All FHIR elements must have a @value or children | |
value | 0..1 | decimal | Non-monetary value ele-1: All FHIR elements must have a @value or children | |
total | Σ | 0..* | BackboneElement | Adjudication totals ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: ?? (example): The adjudication codes. ele-1: All FHIR elements must have a @value or children |
amount | Σ | 1..1 | Money | Financial total for the category ele-1: All FHIR elements must have a @value or children |
payment | 0..1 | BackboneElement | Payment Details ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
type | 1..1 | CodeableConcept | Partial or complete payment Binding: ?? (example): The type (partial, complete) of the payment. ele-1: All FHIR elements must have a @value or children | |
adjustment | 0..1 | Money | Payment adjustment for non-claim issues ele-1: All FHIR elements must have a @value or children | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: ?? (example): Payment Adjustment reason codes. ele-1: All FHIR elements must have a @value or children | |
date | 0..1 | date | Expected date of payment ele-1: All FHIR elements must have a @value or children | |
amount | 1..1 | Money | Payable amount after adjustment ele-1: All FHIR elements must have a @value or children | |
identifier | 0..1 | Identifier | Business identifier for the payment ele-1: All FHIR elements must have a @value or children | |
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: ?? (example): For whom funds are to be reserved: (Patient, Provider, None). ele-1: All FHIR elements must have a @value or children | |
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: ?? (example): The forms codes. ele-1: All FHIR elements must have a @value or children | |
form | 0..1 | Attachment | Printed reference or actual form ele-1: All FHIR elements must have a @value or children | |
processNote | 0..* | BackboneElement | Note concerning adjudication ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
number | 0..1 | positiveInt | Note instance identifier ele-1: All FHIR elements must have a @value or children | |
type | 0..1 | code | display | print | printoper Binding: ?? (required): The presentation types of notes. ele-1: All FHIR elements must have a @value or children | |
text | 1..1 | string | Note explanatory text ele-1: All FHIR elements must have a @value or children | |
language | 0..1 | CodeableConcept | Language of the text Binding: ?? (preferred): A human language. ele-1: All FHIR elements must have a @value or children | |
communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information ele-1: All FHIR elements must have a @value or children | |
insurance | 0..* | BackboneElement | Patient insurance information ele-1: All FHIR elements must have a @value or children | |
extension | 0..* | Extension | Additional content defined by implementations ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
sequence | 1..1 | positiveInt | Insurance instance identifier ele-1: All FHIR elements must have a @value or children | |
focal | 1..1 | boolean | Coverage to be used for adjudication ele-1: All FHIR elements must have a @value or children | |
coverage | 1..1 | Reference(Coverage) | Insurance information ele-1: All FHIR elements must have a @value or children | |
businessArrangement | 0..1 | string | Additional provider contract number ele-1: All FHIR elements must have a @value or children | |
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results ele-1: All FHIR elements must have a @value or children | |
error | S | 0..* | BackboneElement | Processing errors ele-1: All FHIR elements must have a @value or children |
extension | 0..* | Extension | Extension ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
itemSequence | 0..1 | positiveInt | Item sequence number ele-1: All FHIR elements must have a @value or children | |
detailSequence | 0..1 | positiveInt | Detail sequence number ele-1: All FHIR elements must have a @value or children | |
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number ele-1: All FHIR elements must have a @value or children | |
code | S | 1..1 | CodeableConcept | Error code detailing processing issues Binding: ?? (required) ele-1: All FHIR elements must have a @value or children |
Documentation for this format |