Tanzania FHIR Facade Implementation Guide
0.1.0 - ci-build Tanzania

Tanzania FHIR Facade Implementation Guide, published by Ministry of Health – Tanzania. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Speedykom/tz-fhir-ig/ and changes regularly. See the Directory of published versions

Resource Profile: Tanzania ClaimResponse Profile

Official URL: http://moh.tz/fhir/StructureDefinition/tz-claimresponse Version: 0.1.0
Active as of 2025-01-01 Computable Name: TzClaimResponse

Minimal ClaimResponse profile for ZHSF authorization, eligibility, and claim submission responses.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... 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
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... item S 0..* BackboneElement 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
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
Binding: ClaimAdjudicationDecisionsCodes (example)
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
Binding: ClaimAdjudicationDecisionReasonCodes (example)
... payment S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).
.... 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.
.... amount 1..1 Money Payable amount after adjustment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍5.0.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.use Base required Use 📍5.0.0 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​reason Base example Claim Adjudication Decision Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... item S 0..* BackboneElement Adjudication for claim line items
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
... payment S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... traceNumber 0..* Identifier Number for tracking
... 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 0..1 Reference(Organization) Party responsible for reimbursement
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request Σ 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication.
... disposition 0..1 string Disposition Message
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... event 0..* BackboneElement Event 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
.... type 1..1 CodeableConcept Specific event
Binding: DatesTypeCodes (example)
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed.
... encounter 0..* Reference(Encounter) Encounters associated with the listed treatments
... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... item S 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
.... traceNumber 0..* Identifier Number for tracking
.... noteNumber 0..* positiveInt Applicable note numbers
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... 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
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
Binding: ClaimAdjudicationDecisionsCodes (example)
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
Binding: ClaimAdjudicationDecisionReasonCodes (example)
..... preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* 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
..... quantity 0..1 Quantity 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
..... traceNumber 0..* Identifier Number for tracking
..... noteNumber 0..* positiveInt Applicable note numbers
..... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Detail level adjudication results
..... adjudication 0..* 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
...... traceNumber 0..* Identifier Number for tracking
...... noteNumber 0..* positiveInt Applicable note numbers
...... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Subdetail level adjudication results
...... 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
.... traceNumber 0..* Identifier Number for tracking
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
.... request 0..* Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) Request or Referral for Service
.... 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(5.0.0) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... bodySite 0..* BackboneElement Anatomical location
..... 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
..... site 1..* CodeableReference(BodyStructure) Location
Binding: OralSiteCodes (example)
..... subSite 0..* CodeableConcept Sub-location
Binding: SurfaceCodes (example)
.... noteNumber 0..* positiveInt Applicable note numbers
.... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items adjudication results
.... adjudication 0..* 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
..... traceNumber 0..* Identifier Number for tracking
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
..... 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(5.0.0) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... tax 0..1 Money Total tax
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items detail level adjudication results
..... adjudication 0..* 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
...... traceNumber 0..* Identifier Number for tracking
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
...... 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(5.0.0) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items subdetail level adjudication results
...... adjudication 0..* See adjudication (ClaimResponse) Added items subdetail 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 S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).
.... 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: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 CodeableConcept Printed form identifier
Binding: FormCodes (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 CodeableConcept Note purpose
Binding: NoteType (extensible): The presentation types of notes.
.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... 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 Σ 1..1 CodeableConcept Error code detailing processing issues
Binding: AdjudicationErrorCodes (example): The adjudication error codes.
.... expression Σ 0..* string FHIRPath of element(s) related to issue

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.language Base required All Languages 📍5.0.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍5.0.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍5.0.0 FHIR Std.
ClaimResponse.use Base required Use 📍5.0.0 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍5.0.0 FHIR Std.
ClaimResponse.decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.event.​type Base example Dates Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.payeeType Base example Claim Payee Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.diagnosisRelatedGroup Base example Example Diagnosis Related Group Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​reason Base example Claim Adjudication Decision Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​bodySite.site Base example Oral Site Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​bodySite.subSite Base example Surface Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.fundsReserve Base example Funds Reservation Codes 📍5.0.0 FHIR Std.
ClaimResponse.formCode Base example Form Codes 📍5.0.0 FHIR Std.
ClaimResponse.processNote.​type Base extensible NoteType 📍5.0.0 FHIR Std.
ClaimResponse.processNote.​language Base required All Languages 📍5.0.0 FHIR Std.
ClaimResponse.error.​code Base example Adjudication Error Codes 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Must-Support: 6 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... contained 0..* Resource Contained, inline Resources
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... 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
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... item S 0..* BackboneElement 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
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
Binding: ClaimAdjudicationDecisionsCodes (example)
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
Binding: ClaimAdjudicationDecisionReasonCodes (example)
... payment S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).
.... 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.
.... amount 1..1 Money Payable amount after adjustment

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍5.0.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.use Base required Use 📍5.0.0 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​reason Base example Claim Adjudication Decision Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... item S 0..* BackboneElement Adjudication for claim line items
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
... payment S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... traceNumber 0..* Identifier Number for tracking
... 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 0..1 Reference(Organization) Party responsible for reimbursement
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request Σ 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication.
... disposition 0..1 string Disposition Message
... preAuthRef S 0..1 string authorizationNo from ZHSF.
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... event 0..* BackboneElement Event 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
.... type 1..1 CodeableConcept Specific event
Binding: DatesTypeCodes (example)
.... when[x] 1..1 Occurance date or period
..... whenDateTime dateTime
..... whenPeriod Period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed.
... encounter 0..* Reference(Encounter) Encounters associated with the listed treatments
... diagnosisRelatedGroup 0..1 CodeableConcept Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... item S 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
.... traceNumber 0..* Identifier Number for tracking
.... noteNumber 0..* positiveInt Applicable note numbers
.... reviewOutcome S 0..1 BackboneElement Authorization / eligibility decision for this item.
..... 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
..... decision S 0..1 CodeableConcept ACCEPTED / REJECTED / eligible / not_eligible as text/code.
Binding: ClaimAdjudicationDecisionsCodes (example)
..... reason S 0..1 CodeableConcept rejectionReasonID or remarks.
Binding: ClaimAdjudicationDecisionReasonCodes (example)
..... preAuthRef 0..1 string Preauthorization reference
..... preAuthPeriod 0..1 Period Preauthorization reference effective period
.... adjudication 0..* 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
..... quantity 0..1 Quantity 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
..... traceNumber 0..* Identifier Number for tracking
..... noteNumber 0..* positiveInt Applicable note numbers
..... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Detail level adjudication results
..... adjudication 0..* 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
...... traceNumber 0..* Identifier Number for tracking
...... noteNumber 0..* positiveInt Applicable note numbers
...... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Subdetail level adjudication results
...... 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
.... traceNumber 0..* Identifier Number for tracking
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
.... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
.... request 0..* Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) Request or Referral for Service
.... 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(5.0.0) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... tax 0..1 Money Total tax
.... net 0..1 Money Total item cost
.... bodySite 0..* BackboneElement Anatomical location
..... 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
..... site 1..* CodeableReference(BodyStructure) Location
Binding: OralSiteCodes (example)
..... subSite 0..* CodeableConcept Sub-location
Binding: SurfaceCodes (example)
.... noteNumber 0..* positiveInt Applicable note numbers
.... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items adjudication results
.... adjudication 0..* 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
..... traceNumber 0..* Identifier Number for tracking
..... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
..... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
..... 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(5.0.0) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... tax 0..1 Money Total tax
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items detail level adjudication results
..... adjudication 0..* 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
...... traceNumber 0..* Identifier Number for tracking
...... revenue 0..1 CodeableConcept Revenue or cost center code
Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products.
...... productOrService 0..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... productOrServiceEnd 0..1 CodeableConcept End of a range of codes
Binding: USCLSCodes (example)
...... 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(5.0.0) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... tax 0..1 Money Total tax
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... reviewOutcome 0..1 See reviewOutcome (ClaimResponse) Added items subdetail level adjudication results
...... adjudication 0..* See adjudication (ClaimResponse) Added items subdetail 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 S 0..1 BackboneElement Totals from PaymentBatches (AmountAccepted, adjustments etc.).
.... 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: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 CodeableConcept Printed form identifier
Binding: FormCodes (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 CodeableConcept Note purpose
Binding: NoteType (extensible): The presentation types of notes.
.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: AllLanguages (required): IETF language tag for a human language
Additional BindingsPurpose
CommonLanguages Starter
... 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 Σ 1..1 CodeableConcept Error code detailing processing issues
Binding: AdjudicationErrorCodes (example): The adjudication error codes.
.... expression Σ 0..* string FHIRPath of element(s) related to issue

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.language Base required All Languages 📍5.0.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍5.0.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍5.0.0 FHIR Std.
ClaimResponse.use Base required Use 📍5.0.0 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍5.0.0 FHIR Std.
ClaimResponse.decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.event.​type Base example Dates Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.payeeType Base example Claim Payee Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.diagnosisRelatedGroup Base example Example Diagnosis Related Group Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​decision Base example Claim Adjudication Decision Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.reviewOutcome.​reason Base example Claim Adjudication Decision Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍5.0.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​bodySite.site Base example Oral Site Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​bodySite.subSite Base example Surface Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.revenue Base example Example Revenue Center Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrServiceEnd Base example USCLS Codes 📍5.0.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍5.0.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍5.0.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍5.0.0 FHIR Std.
ClaimResponse.fundsReserve Base example Funds Reservation Codes 📍5.0.0 FHIR Std.
ClaimResponse.formCode Base example Form Codes 📍5.0.0 FHIR Std.
ClaimResponse.processNote.​type Base extensible NoteType 📍5.0.0 FHIR Std.
ClaimResponse.processNote.​language Base required All Languages 📍5.0.0 FHIR Std.
ClaimResponse.error.​code Base example Adjudication Error Codes 📍5.0.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Must-Support: 6 elements

 

Other representations of profile: CSV, Excel, Schematron