QI-Core Implementation Guide
7.0.0 - STU7 United States of America flag

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

Resource Profile: QICore ClaimResponse

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-claimresponse Version: 7.0.0
Draft as of 2022-04-20 Computable Name: QICoreClaimResponse

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The QI-Core ClaimResponse profile is used to provide the results of the adjudication and/or authorization of a set of healthcare-related products and services for a patient against the patient's insurance coverages, or to respond with what the adjudication would be for a supplied set of products or services should they be actually supplied to the patient. It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the ClaimResponse resource when using this profile

QI Elements:
  • status: (QI) active | cancelled | draft | entered-in-error
  • type: (QI) More granular claim type
  • use: (QI) claim | preauthorization | predetermination
  • patient: (QI) The recipient of the products and services
  • created: (QI) Response creation date
  • insurer: (QI) Party responsible for reimbursement
  • requestor: (QI) Party responsible for the claim
  • request: (QI) Id of resource triggering adjudication
  • item: (QI) Adjudication for claim line items
  • item.adjudication: (QI) Adjudication details
  • item.adjudication.category: (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
  • item.adjudication.amount: (QI) Monetary amount
  • item.detail.detailSequence: (QI) Claim detail instance identifier
Primary code path: type
(PCPath) This element is the primary code path for this resource CQL Retrieve


NOTE TO BALLOT REVIEWERS:
  • US Core 7.0, and thus QI-Core 7.0, has a new approach to USCDI requirements.
    • As noted in the US Core 7.0 Must Support section, US Core 7.0 no longer highlights mandatory (cardinality 1..* or 1..1) and Must Support elements with a (USCDI) indicator as such items must be supported for interoperability.
    • Those USCDI elements that are not mandatory or Must Support now include an indicator (ADDITIONAL USCDI) in US Core. QI-Core 7.0 does not reference USCDI elements; rather, users should access US Core 7.0 to understand its implementation of USCDI version 4.
  • We invite comments about the approach and suggestions for other options that would also avoid unnecessary noise or reading load to the QI-Core profile representation.
  • Further, QI-Core 7.0 does not discuss USCDI+Quality because at the time of ballot preparation, no published version of USCDI+Quality is available. We seek reviewer advice regarding how QI-Core might address future USCDI+Quality.

Usage

See the patterns page for implementation and usage patterns.

Examples

Preauthorization Vision ClaimResponse Example

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type Σ 1..1 CodeableConcept (QI) More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... item 0..* BackboneElement (QI) Adjudication for claim line items
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... amount 0..1 Money (QI) Monetary amount
.... detail
..... detailSequence 1..1 positiveInt (QI) Claim detail instance identifier

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ 1..1 Reference(QICore Patient) (QI) The recipient of the products and services
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... item 0..* BackboneElement (QI) Adjudication for claim line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... amount 0..1 Money (QI) Monetary amount

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type Σ 1..1 CodeableConcept (QI) More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ 1..1 Reference(QICore Patient) (QI) The recipient of the products and services
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..* BackboneElement (QI) Adjudication for claim line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Binding: AdjudicationValueCodes (example): The adjudication codes.


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: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1 Money (QI) Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt (QI) Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
.... detail 0..* BackboneElement Insurer added line details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1 date Expected date of payment
.... amount 1..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..1 positiveInt Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type Σ 1..1 CodeableConcept (QI) More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... item 0..* BackboneElement (QI) Adjudication for claim line items
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... amount 0..1 Money (QI) Monetary amount
.... detail
..... detailSequence 1..1 positiveInt (QI) Claim detail instance identifier

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ 1..1 Reference(QICore Patient) (QI) The recipient of the products and services
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... item 0..* BackboneElement (QI) Adjudication for claim line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Binding: AdjudicationValueCodes (example): The adjudication codes.


Required Pattern: At least the following
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/adjudication
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: submitted
..... amount 0..1 Money (QI) Monetary amount

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!Σ 1..1 code (QI) active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


Fixed Value: active
... type Σ 1..1 CodeableConcept (QI) More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 1..1 code (QI) claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


Fixed Value: preauthorization
... patient Σ 1..1 Reference(QICore Patient) (QI) The recipient of the products and services
... created Σ 1..1 dateTime (QI) Response creation date
... insurer Σ 1..1 Reference(QICore Organization) (QI) Party responsible for reimbursement
... requestor 0..1 Reference(QICore Practitioner | QICore Organization | QICore PractitionerRole) (QI) Party responsible for the claim
... request Σ 0..1 Reference(QICore Claim) (QI) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..* BackboneElement (QI) Adjudication for claim line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement (QI) Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept (QI) This code is fixed to 'submitted' to indicate that the adjudication result is on what was submitted.
Binding: AdjudicationValueCodes (example): The adjudication codes.


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: AdjudicationReasonCodes (example): The adjudication reason codes.

..... amount 0..1 Money (QI) Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt (QI) Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
.... detail 0..* BackboneElement Insurer added line details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


..... quantity 0..1 SimpleQuantity Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.


...... quantity 0..1 SimpleQuantity Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1 date Expected date of payment
.... amount 1..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..1 positiveInt Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.statusrequiredFixed Value: active
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredFixed Value: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexamplePattern: submitted
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

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