Finance and Insurance Service (FAIS)
1.0.0-current - ci-build
Finance and Insurance Service (FAIS), published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 1.0.0-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/ITI.Finance/ and changes regularly. See the Directory of published versions
Official URL: https://profiles.ihe.net/ITI/FAIS/StructureDefinition/IHE.FAIS.ClaimResponse | Version: 1.0.0-current | |||
Active as of 2024-10-24 | Computable Name: FAISClaimResponse |
The FAIS ClaimResponse profile to be used as the response to the FAIS Claim $submit
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | ClaimResponse | |||
implicitRules | 0..0 | |||
modifierExtension | 0..0 | |||
request | 1..1 | Reference(FAIS Claim Profile) | Id of resource triggering adjudication | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. |
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | Response creation date |
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
request | Σ | 1..1 | Reference(FAIS Claim Profile) | Id of resource triggering adjudication |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | 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 | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. | ||||
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |||||
request | Σ | 1..1 | Reference(FAIS Claim Profile) | 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 | 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 | 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 | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
amount | 0..1 | Money | 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 | 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.
| |||||
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. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | ||||
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | ||||
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | ||||
ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard | ||||
ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClaimResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
This structure is derived from ClaimResponse
Differential View
This structure is derived from ClaimResponse
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | ClaimResponse | |||
implicitRules | 0..0 | |||
modifierExtension | 0..0 | |||
request | 1..1 | Reference(FAIS Claim Profile) | Id of resource triggering adjudication | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. |
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. |
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. |
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services |
created | Σ | 1..1 | dateTime | Response creation date |
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement |
request | Σ | 1..1 | Reference(FAIS Claim Profile) | Id of resource triggering adjudication |
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. |
Documentation for this format |
Path | Conformance | ValueSet | URI |
ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. | ||||
type | Σ | 1..1 | CodeableConcept | 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 | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. | ||||
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement | ||||
requestor | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim | |||||
request | Σ | 1..1 | Reference(FAIS Claim Profile) | 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 | 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 | 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 | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
reason | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
amount | 0..1 | Money | 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 | 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.
| |||||
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. | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
ClaimResponse.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1 from the FHIR Standard | ||||
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | ||||
ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | ||||
ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1 from the FHIR Standard | ||||
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 from the FHIR Standard | ||||
ClaimResponse.payeeType | example | Claim Payee Type Codeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | ||||
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | ||||
ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | ||||
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | ||||
ClaimResponse.addItem.bodySite | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | ||||
ClaimResponse.addItem.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | ||||
ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | ||||
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | ||||
ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | ||||
ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | ||||
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | ||||
ClaimResponse.fundsReserve | example | Funds Reservation Codeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | ||||
ClaimResponse.formCode | example | Form Codeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | ||||
ClaimResponse.processNote.type | required | NoteTypehttp://hl7.org/fhir/ValueSet/note-type|4.0.1 from the FHIR Standard | ||||
ClaimResponse.processNote.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
ClaimResponse.error.code | example | Adjudication Error Codeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
This structure is derived from ClaimResponse
Other representations of profile: CSV, Excel, Schematron