臺灣健保事前審查實作指引
1.2.8 - ci-build

臺灣健保事前審查實作指引, published by 衛生福利部中央健康保險署. This guide is not an authorized publication; it is the continuous build for version 1.2.8 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/TWNHIFHIR/pas/ and changes regularly. See the Directory of published versions

Resource Profile: 自主審查-ClaimResponse Self Assessment TWPAS

Official URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas Version: 1.2.8
Active as of 2026-10-14 Computable Name: ClaimResponseSelfAssessmentTWPAS

此自主審查-ClaimResponse TWPAS Profile說明本IG如何進一步定義FHIR的ClaimResponse Resource以呈現自主審查之內容。

現行開放自主事前審查項目僅有心臟及肝臟移植，若醫院要自主事前審查需向健保署申請，通過後，健保署會於署內系統維護，具有此資格之院所才可填報自主審查。

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: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.meta This element is included in summaries. 1..1 Meta Metadata about the resource
ClaimResponse.meta.profile This element is included in summaries. 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
ClaimResponse.type This element is included in summaries. 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
ClaimResponse.type.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.coding.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.version 0..1 string Version of the system - if relevant
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.type.coding.display 0..1 string Representation defined by the system
ClaimResponse.type.coding.userSelected 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.type.text 0..1 string Plain text representation of the concept
ClaimResponse.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
Required Pattern: preauthorization
ClaimResponse.patient This element is included in summaries. 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. This element is included in summaries. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()
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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 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: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.meta 1..1 Meta Metadata about the resource
ClaimResponse.meta.profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.use 1..1 code claim | preauthorization | predetermination
Required Pattern: preauthorization
ClaimResponse.patient 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
ClaimResponse.item.adjudication.category.coding
ClaimResponse.item.adjudication.category.coding.system 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.adjudication.category.coding.code 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.id This element is included in summaries. 0..1 id Logical id of this artifact
ClaimResponse.meta This element is included in summaries. 1..1 Meta Metadata about the resource
ClaimResponse.meta.id 0..1 string Unique id for inter-element referencing
ClaimResponse.meta.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
ClaimResponse.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource version last changed
ClaimResponse.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
ClaimResponse.meta.profile This element is included in summaries. 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
ClaimResponse.meta.tag This element is included in summaries. 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
ClaimResponse.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
ClaimResponse.language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
ClaimResponse.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
ClaimResponse.contained 0..* Resource Contained, inline Resources
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier Business Identifier for a claim response
ClaimResponse.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
ClaimResponse.type This element is included in summaries. 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
ClaimResponse.type.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.coding.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.version 0..1 string Version of the system - if relevant
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.type.coding.display 0..1 string Representation defined by the system
ClaimResponse.type.coding.userSelected 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.type.text 0..1 string Plain text representation of the concept
ClaimResponse.subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
ClaimResponse.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
Required Pattern: preauthorization
ClaimResponse.patient This element is included in summaries. 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. This element is included in summaries. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
ClaimResponse.request This element is included in summaries. 0..1 Reference(Claim) Id of resource triggering adjudication
ClaimResponse.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.preAuthRef 0..1 string Preauthorization reference
ClaimResponse.preAuthPeriod 0..1 Period Preauthorization reference effective period
ClaimResponse.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.
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.adjudication.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.adjudication.category.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.adjudication.category.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.coding.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.category.coding.system This element is included in summaries. 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.adjudication.category.coding.version This element is included in summaries. 0..1 string Version of the system - if relevant
ClaimResponse.item.adjudication.category.coding.code This element is included in summaries. 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.adjudication.category.coding.display This element is included in summaries. 0..1 string Representation defined by the system
ClaimResponse.item.adjudication.category.coding.userSelected This element is included in summaries. 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.item.adjudication.category.text This element is included in summaries. 0..1 string Plain text representation of the concept
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。
ClaimResponse.item.detail 0..* BackboneElement Adjudication for claim details
ClaimResponse.item.detail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.detail.detailSequence 1..1 positiveInt Claim detail instance identifier
ClaimResponse.item.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
ClaimResponse.item.detail.subDetail 0..* BackboneElement Adjudication for claim sub-details
ClaimResponse.item.detail.subDetail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.subDetail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.subDetail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.detail.subDetail.subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
ClaimResponse.item.detail.subDetail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.subDetail.adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
ClaimResponse.addItem 0..* BackboneElement Insurer added line items
ClaimResponse.addItem.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.itemSequence 0..* positiveInt Item sequence number
ClaimResponse.addItem.detailSequence 0..* positiveInt Detail sequence number
ClaimResponse.addItem.subdetailSequence 0..* positiveInt Subdetail sequence number
ClaimResponse.addItem.provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
ClaimResponse.addItem.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.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.
ClaimResponse.addItem.programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
ClaimResponse.addItem.serviced[x] 0..1 Date or dates of service or product delivery
ClaimResponse.addItem.serviced[x].servicedDate date
ClaimResponse.addItem.serviced[x].servicedPeriod Period
ClaimResponse.addItem.location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
ClaimResponse.addItem.location[x].locationCodeableConcept CodeableConcept
ClaimResponse.addItem.location[x].locationAddress Address
ClaimResponse.addItem.location[x].locationReference Reference(Location)
ClaimResponse.addItem.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.net 0..1 Money Total item cost
ClaimResponse.addItem.bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
ClaimResponse.addItem.subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
ClaimResponse.addItem.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
ClaimResponse.addItem.detail 0..* BackboneElement Insurer added line details
ClaimResponse.addItem.detail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.detail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.detail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.detail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.detail.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.
ClaimResponse.addItem.detail.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.detail.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.detail.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.detail.net 0..1 Money Total item cost
ClaimResponse.addItem.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.detail.adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
ClaimResponse.addItem.detail.subDetail 0..* BackboneElement Insurer added line items
ClaimResponse.addItem.detail.subDetail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.detail.subDetail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.detail.subDetail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.detail.subDetail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.detail.subDetail.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.
ClaimResponse.addItem.detail.subDetail.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.detail.subDetail.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.detail.subDetail.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.detail.subDetail.net 0..1 Money Total item cost
ClaimResponse.addItem.detail.subDetail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.detail.subDetail.adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
ClaimResponse.adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
ClaimResponse.total This element is included in summaries. 0..* BackboneElement Adjudication totals
ClaimResponse.total.id 0..1 string Unique id for inter-element referencing
ClaimResponse.total.extension 0..* Extension Additional content defined by implementations
ClaimResponse.total.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.total.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.total.amount This element is included in summaries. 1..1 Money Financial total for the category
ClaimResponse.payment 0..1 BackboneElement Payment Details
ClaimResponse.payment.id 0..1 string Unique id for inter-element referencing
ClaimResponse.payment.extension 0..* Extension Additional content defined by implementations
ClaimResponse.payment.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.payment.type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
ClaimResponse.payment.adjustment 0..1 Money Payment adjustment for non-claim issues
ClaimResponse.payment.adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
ClaimResponse.payment.date 0..1 date Expected date of payment
ClaimResponse.payment.amount 1..1 Money Payable amount after adjustment
ClaimResponse.payment.identifier 0..1 Identifier Business identifier for the payment
ClaimResponse.fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
ClaimResponse.formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
ClaimResponse.form 0..1 Attachment Printed reference or actual form
ClaimResponse.processNote 0..* BackboneElement Note concerning adjudication
ClaimResponse.processNote.id 0..1 string Unique id for inter-element referencing
ClaimResponse.processNote.extension 0..* Extension Additional content defined by implementations
ClaimResponse.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.processNote.number 0..1 positiveInt Note instance identifier
ClaimResponse.processNote.type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
ClaimResponse.processNote.text 1..1 string Note explanatory text
ClaimResponse.processNote.language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
ClaimResponse.communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
ClaimResponse.insurance 0..* BackboneElement Patient insurance information
ClaimResponse.insurance.id 0..1 string Unique id for inter-element referencing
ClaimResponse.insurance.extension 0..* Extension Additional content defined by implementations
ClaimResponse.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.insurance.sequence 1..1 positiveInt Insurance instance identifier
ClaimResponse.insurance.focal 1..1 boolean Coverage to be used for adjudication
ClaimResponse.insurance.coverage 1..1 Reference(Coverage) Insurance information
ClaimResponse.insurance.businessArrangement 0..1 string Additional provider contract number
ClaimResponse.insurance.claimResponse 0..1 Reference(ClaimResponse) Adjudication results
ClaimResponse.error 0..* BackboneElement Processing errors
ClaimResponse.error.id 0..1 string Unique id for inter-element referencing
ClaimResponse.error.extension 0..* Extension Additional content defined by implementations
ClaimResponse.error.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.error.itemSequence 0..1 positiveInt Item sequence number
ClaimResponse.error.detailSequence 0..1 positiveInt Detail sequence number
ClaimResponse.error.subDetailSequence 0..1 positiveInt Subdetail sequence number
ClaimResponse.error.code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()
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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 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()
sqty-1 error ClaimResponse.addItem.quantity, ClaimResponse.addItem.detail.quantity, ClaimResponse.addItem.detail.subDetail.quantity The comparator is not used on a SimpleQuantity comparator.empty()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.meta This element is included in summaries. 1..1 Meta Metadata about the resource
ClaimResponse.meta.profile This element is included in summaries. 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
ClaimResponse.type This element is included in summaries. 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
ClaimResponse.type.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.coding.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.version 0..1 string Version of the system - if relevant
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.type.coding.display 0..1 string Representation defined by the system
ClaimResponse.type.coding.userSelected 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.type.text 0..1 string Plain text representation of the concept
ClaimResponse.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
Required Pattern: preauthorization
ClaimResponse.patient This element is included in summaries. 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. This element is included in summaries. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()
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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 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: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.meta 1..1 Meta Metadata about the resource
ClaimResponse.meta.profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
ClaimResponse.type 1..1 CodeableConcept More granular claim type
Required Pattern: At least the following
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.use 1..1 code claim | preauthorization | predetermination
Required Pattern: preauthorization
ClaimResponse.patient 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
ClaimResponse.item.adjudication.category.coding
ClaimResponse.item.adjudication.category.coding.system 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.adjudication.category.coding.code 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: acceptanceStatus
ClaimResponse.id This element is included in summaries. 0..1 id Logical id of this artifact
ClaimResponse.meta This element is included in summaries. 1..1 Meta Metadata about the resource
ClaimResponse.meta.id 0..1 string Unique id for inter-element referencing
ClaimResponse.meta.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.meta.versionId This element is included in summaries. 0..1 id Version specific identifier
ClaimResponse.meta.lastUpdated This element is included in summaries. 0..1 instant When the resource version last changed
ClaimResponse.meta.source This element is included in summaries. 0..1 uri Identifies where the resource comes from
ClaimResponse.meta.profile This element is included in summaries. 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to

Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
ClaimResponse.meta.security This element is included in summaries. 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
ClaimResponse.meta.tag This element is included in summaries. 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
ClaimResponse.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
ClaimResponse.language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
ClaimResponse.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
ClaimResponse.contained 0..* Resource Contained, inline Resources
ClaimResponse.Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url

Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
ClaimResponse.Slices for extension.extension:requestor This element must be supported. 1..* Identifier 審查委員身分證號
URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier Business Identifier for a claim response
ClaimResponse.status This element is a modifier element. This element is included in summaries. 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
ClaimResponse.type This element is included in summaries. 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
Required Pattern: At least the following
ClaimResponse.type.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
ClaimResponse.type.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.type.coding.extension 0..* Extension Additional content defined by implementations
ClaimResponse.type.coding.system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
ClaimResponse.type.coding.version 0..1 string Version of the system - if relevant
ClaimResponse.type.coding.code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
ClaimResponse.type.coding.display 0..1 string Representation defined by the system
ClaimResponse.type.coding.userSelected 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.type.text 0..1 string Plain text representation of the concept
ClaimResponse.subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
ClaimResponse.use This element is included in summaries. 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
Required Pattern: preauthorization
ClaimResponse.patient This element is included in summaries. 1..1 Reference(病人資訊-Patient TWPAS) The recipient of the products and services
ClaimResponse.created This element must be supported. This element is included in summaries. 1..1 dateTime 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
ClaimResponse.request This element is included in summaries. 0..1 Reference(Claim) Id of resource triggering adjudication
ClaimResponse.outcome This element is included in summaries. 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
ClaimResponse.disposition This element must be supported. 0..1 string 核定意見
ClaimResponse.preAuthRef 0..1 string Preauthorization reference
ClaimResponse.preAuthPeriod 0..1 Period Preauthorization reference effective period
ClaimResponse.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.
ClaimResponse.item 1..* BackboneElement Adjudication for claim line items
ClaimResponse.item.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.itemSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.adjudication 1..1 BackboneElement Adjudication details
ClaimResponse.item.adjudication.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.adjudication.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.adjudication.category.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.adjudication.category.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.category.coding.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.category.coding.system This element is included in summaries. 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.adjudication.category.coding.version This element is included in summaries. 0..1 string Version of the system - if relevant
ClaimResponse.item.adjudication.category.coding.code This element is included in summaries. 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.adjudication.category.coding.display This element is included in summaries. 0..1 string Representation defined by the system
ClaimResponse.item.adjudication.category.coding.userSelected This element is included in summaries. 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.item.adjudication.category.text This element is included in summaries. 0..1 string Plain text representation of the concept
ClaimResponse.item.adjudication.reason This element must be supported. 1..1 CodeableConcept 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見
Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
ClaimResponse.item.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.adjudication.value This element must be supported. 1..1 decimal 個別審查結果數量，若申請案件類別為3時須填寫。
ClaimResponse.item.detail 0..* BackboneElement Adjudication for claim details
ClaimResponse.item.detail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.detail.detailSequence 1..1 positiveInt Claim detail instance identifier
ClaimResponse.item.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
ClaimResponse.item.detail.subDetail 0..* BackboneElement Adjudication for claim sub-details
ClaimResponse.item.detail.subDetail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.subDetail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.subDetail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.item.detail.subDetail.subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
ClaimResponse.item.detail.subDetail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.subDetail.adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
ClaimResponse.addItem 0..* BackboneElement Insurer added line items
ClaimResponse.addItem.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.itemSequence 0..* positiveInt Item sequence number
ClaimResponse.addItem.detailSequence 0..* positiveInt Detail sequence number
ClaimResponse.addItem.subdetailSequence 0..* positiveInt Subdetail sequence number
ClaimResponse.addItem.provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
ClaimResponse.addItem.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.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.
ClaimResponse.addItem.programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
ClaimResponse.addItem.serviced[x] 0..1 Date or dates of service or product delivery
ClaimResponse.addItem.serviced[x].servicedDate date
ClaimResponse.addItem.serviced[x].servicedPeriod Period
ClaimResponse.addItem.location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
ClaimResponse.addItem.location[x].locationCodeableConcept CodeableConcept
ClaimResponse.addItem.location[x].locationAddress Address
ClaimResponse.addItem.location[x].locationReference Reference(Location)
ClaimResponse.addItem.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.net 0..1 Money Total item cost
ClaimResponse.addItem.bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
ClaimResponse.addItem.subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
ClaimResponse.addItem.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
ClaimResponse.addItem.detail 0..* BackboneElement Insurer added line details
ClaimResponse.addItem.detail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.detail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.detail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.detail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.detail.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.
ClaimResponse.addItem.detail.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.detail.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.detail.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.detail.net 0..1 Money Total item cost
ClaimResponse.addItem.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.detail.adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
ClaimResponse.addItem.detail.subDetail 0..* BackboneElement Insurer added line items
ClaimResponse.addItem.detail.subDetail.id 0..1 string Unique id for inter-element referencing
ClaimResponse.addItem.detail.subDetail.extension 0..* Extension Additional content defined by implementations
ClaimResponse.addItem.detail.subDetail.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.addItem.detail.subDetail.productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
ClaimResponse.addItem.detail.subDetail.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.
ClaimResponse.addItem.detail.subDetail.quantity C 0..1 SimpleQuantity(4.0.1) Count of products or services
Constraints: sqty-1
ClaimResponse.addItem.detail.subDetail.unitPrice 0..1 Money Fee, charge or cost per item
ClaimResponse.addItem.detail.subDetail.factor 0..1 decimal Price scaling factor
ClaimResponse.addItem.detail.subDetail.net 0..1 Money Total item cost
ClaimResponse.addItem.detail.subDetail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.addItem.detail.subDetail.adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
ClaimResponse.adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
ClaimResponse.total This element is included in summaries. 0..* BackboneElement Adjudication totals
ClaimResponse.total.id 0..1 string Unique id for inter-element referencing
ClaimResponse.total.extension 0..* Extension Additional content defined by implementations
ClaimResponse.total.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.total.category This element is included in summaries. 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.total.amount This element is included in summaries. 1..1 Money Financial total for the category
ClaimResponse.payment 0..1 BackboneElement Payment Details
ClaimResponse.payment.id 0..1 string Unique id for inter-element referencing
ClaimResponse.payment.extension 0..* Extension Additional content defined by implementations
ClaimResponse.payment.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.payment.type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
ClaimResponse.payment.adjustment 0..1 Money Payment adjustment for non-claim issues
ClaimResponse.payment.adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
ClaimResponse.payment.date 0..1 date Expected date of payment
ClaimResponse.payment.amount 1..1 Money Payable amount after adjustment
ClaimResponse.payment.identifier 0..1 Identifier Business identifier for the payment
ClaimResponse.fundsReserve 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
ClaimResponse.formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
ClaimResponse.form 0..1 Attachment Printed reference or actual form
ClaimResponse.processNote 0..* BackboneElement Note concerning adjudication
ClaimResponse.processNote.id 0..1 string Unique id for inter-element referencing
ClaimResponse.processNote.extension 0..* Extension Additional content defined by implementations
ClaimResponse.processNote.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.processNote.number 0..1 positiveInt Note instance identifier
ClaimResponse.processNote.type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
ClaimResponse.processNote.text 1..1 string Note explanatory text
ClaimResponse.processNote.language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
ClaimResponse.communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
ClaimResponse.insurance 0..* BackboneElement Patient insurance information
ClaimResponse.insurance.id 0..1 string Unique id for inter-element referencing
ClaimResponse.insurance.extension 0..* Extension Additional content defined by implementations
ClaimResponse.insurance.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.insurance.sequence 1..1 positiveInt Insurance instance identifier
ClaimResponse.insurance.focal 1..1 boolean Coverage to be used for adjudication
ClaimResponse.insurance.coverage 1..1 Reference(Coverage) Insurance information
ClaimResponse.insurance.businessArrangement 0..1 string Additional provider contract number
ClaimResponse.insurance.claimResponse 0..1 Reference(ClaimResponse) Adjudication results
ClaimResponse.error 0..* BackboneElement Processing errors
ClaimResponse.error.id 0..1 string Unique id for inter-element referencing
ClaimResponse.error.extension 0..* Extension Additional content defined by implementations
ClaimResponse.error.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
ClaimResponse.error.itemSequence 0..1 positiveInt Item sequence number
ClaimResponse.error.detailSequence 0..1 positiveInt Detail sequence number
ClaimResponse.error.subDetailSequence 0..1 positiveInt Subdetail sequence number
ClaimResponse.error.code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-個別醫令核定註記值集 📦1.2.8 This IG
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
acceptanceStatus error ClaimResponse 若個別醫令核定註記(item.adjudication.reason)為2、3、4、5、6、7時，核定意見(disposition)為必填。 item.adjudication.reason.coding.where(code in ('2' | '3' | '4' | '5' | '6' | '7')).exists() implies disposition.exists()
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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 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()
sqty-1 error ClaimResponse.addItem.quantity, ClaimResponse.addItem.detail.quantity, ClaimResponse.addItem.detail.subDetail.quantity The comparator is not used on a SimpleQuantity comparator.empty()

 

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