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: 事前審查回覆-ClaimResponse TWPAS

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

此事前審查回覆-ClaimResponse TWPAS Profile說明本IG如何進一步定義FHIR的ClaimResponse Resource以呈現事前審查回覆之內容

案件核定結果係綜合該申請案件醫令審核結果做為判斷依據，規則說明如下：

  1. 所有醫令皆核定為1-同意，則該案件審查結果為1-同意。
  2. 非所有醫令核定為1-同意，其中有一醫令核定為1-同意或3-部分同意，則該案件審查結果為3-部分同意。
  3. 所有醫令皆核定為2-不同意或6-不予同意，則該案件審查結果為2-不同意。
  4. 排除上述1、2、3規則，案件中有一醫令核定為補件，則該案件審查結果為4-補件。
  5. 排除上述1、2、3規則，案件中有一醫令核定為退件，則該案件審查結果為5-退件。
  6. 若核定註記為7-改核:如審查核定意見，則判斷申請量與審查結果數量，若核定同總申請量，該醫令核定註記視為
    • 同意;若核定量為0(空值視同0)，該醫令核定註記視為2-不同意;核定量小於總申請量，該醫令核定註記視為3-部分同意。並綜合該申請案件醫令審核結果，作為該案件審查結果(同上述五點)。

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 0..* ClaimResponse Response to a claim predetermination or preauthorization
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-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.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Required Pattern: official
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. This element is included in summaries. 1..1 Reference(癌藥事前審查-Claim TWPAS) 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. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
ClaimResponse.item 1..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 Claim item instance identifier
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.text This element must be supported. This element is included in summaries. 0..1 string 核定意見
ClaimResponse.item.detail 1..* BackboneElement Adjudication for claim details
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 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.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.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.detail.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.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📍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.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
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-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.detail.​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
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 ClaimResponse
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-twpas
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.use 0..1 code usual | official | temp | secondary | old (If known)
Required Pattern: official
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. 1..1 Reference(癌藥事前審查-Claim TWPAS) Id of resource triggering adjudication
ClaimResponse.disposition This element must be supported. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
ClaimResponse.item 1..1 BackboneElement Adjudication for claim line items
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.text This element must be supported. 0..1 string 核定意見
ClaimResponse.item.detail 1..* BackboneElement Adjudication for claim details
ClaimResponse.item.detail.detailSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
ClaimResponse.item.detail.adjudication.category.coding
ClaimResponse.item.detail.adjudication.category.coding.system 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.detail.adjudication.category.coding.code 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.detail.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.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​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
NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
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-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.extension 0..* Extension Additional content defined by implementations
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.id 0..1 string Unique id for inter-element referencing
ClaimResponse.identifier.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.identifier.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Required Pattern: official
ClaimResponse.identifier.type This element is included in summaries. 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
ClaimResponse.identifier.system This element is included in summaries. 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
ClaimResponse.identifier.value This element is included in summaries. 0..1 string The value that is unique
Example General: 123456
ClaimResponse.identifier.period This element is included in summaries. 0..1 Period Time period when id is/was valid for use
ClaimResponse.identifier.assigner This element is included in summaries. 0..1 Reference(Organization) Organization that issued id (may be just text)
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. This element is included in summaries. 1..1 Reference(癌藥事前審查-Claim TWPAS) 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. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
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..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 Claim item instance identifier
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.reason.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.reason.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.adjudication.reason.text This element must be supported. This element is included in summaries. 0..1 string 核定意見
ClaimResponse.item.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.adjudication.value 0..1 decimal Non-monetary value
ClaimResponse.item.detail 1..* 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 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.adjudication.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.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.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.detail.adjudication.category.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.category.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.detail.adjudication.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.detail.adjudication.category.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.category.coding.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.detail.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.detail.adjudication.category.coding.version This element is included in summaries. 0..1 string Version of the system - if relevant
ClaimResponse.item.detail.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.detail.adjudication.category.coding.display This element is included in summaries. 0..1 string Representation defined by the system
ClaimResponse.item.detail.adjudication.category.coding.userSelected This element is included in summaries. 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.item.detail.adjudication.category.text This element is included in summaries. 0..1 string Plain text representation of the concept
ClaimResponse.item.detail.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.detail.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量
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.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📍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.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
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-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.detail.​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
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 0..* ClaimResponse Response to a claim predetermination or preauthorization
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-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.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Required Pattern: official
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. This element is included in summaries. 1..1 Reference(癌藥事前審查-Claim TWPAS) 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. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
ClaimResponse.item 1..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 Claim item instance identifier
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.text This element must be supported. This element is included in summaries. 0..1 string 核定意見
ClaimResponse.item.detail 1..* BackboneElement Adjudication for claim details
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 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.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.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.detail.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.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📍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.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
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-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.detail.​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
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 ClaimResponse
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-twpas
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.use 0..1 code usual | official | temp | secondary | old (If known)
Required Pattern: official
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. 1..1 Reference(癌藥事前審查-Claim TWPAS) Id of resource triggering adjudication
ClaimResponse.disposition This element must be supported. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
ClaimResponse.item 1..1 BackboneElement Adjudication for claim line items
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.text This element must be supported. 0..1 string 核定意見
ClaimResponse.item.detail 1..* BackboneElement Adjudication for claim details
ClaimResponse.item.detail.detailSequence 1..1 positiveInt 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
ClaimResponse.item.detail.adjudication.category.coding
ClaimResponse.item.detail.adjudication.category.coding.system 0..1 uri Identity of the terminology system
Example General: http://terminology.hl7.org/CodeSystem/adjudication
ClaimResponse.item.detail.adjudication.category.coding.code 0..1 code Symbol in syntax defined by the system
Example General: submitted
ClaimResponse.item.detail.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.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
ClaimResponse.item.adjudication.​reason Base required NHI-健保事前審查-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​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

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: doco
ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
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-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.extension 0..* Extension Additional content defined by implementations
ClaimResponse.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
ClaimResponse.identifier 0..* Identifier 受理編號。供案件追蹤與識別使用，醫院上傳時無須填寫。
ClaimResponse.identifier.id 0..1 string Unique id for inter-element referencing
ClaimResponse.identifier.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.identifier.use This element is a modifier element. This element is included in summaries. 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Required Pattern: official
ClaimResponse.identifier.type This element is included in summaries. 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
ClaimResponse.identifier.system This element is included in summaries. 0..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
ClaimResponse.identifier.value This element is included in summaries. 0..1 string The value that is unique
Example General: 123456
ClaimResponse.identifier.period This element is included in summaries. 0..1 Period Time period when id is/was valid for use
ClaimResponse.identifier.assigner This element is included in summaries. 0..1 Reference(Organization) Organization that issued id (may be just text)
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 核定日期或受理日期，即為案件受理狀態(disposition)之異動日期，依據其狀態不同而有不同日期，例如案件受理狀態為已受理，此日期則為受理日期；若為審畢結果則為核定日期。
ClaimResponse.insurer This element is included in summaries. 1..1 Reference(TW Core Organization Government) Party responsible for reimbursement
ClaimResponse.requestor This element must be supported. 1..1 Reference(醫事機構-Organization TWPAS) Party responsible for the claim
ClaimResponse.request This element must be supported. This element is included in summaries. 1..1 Reference(癌藥事前審查-Claim TWPAS) 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. 1..1 string 案件受理狀態。待處理 | 處理中 | 處理中(等待附件檔) | 處理中(檔案檢核中) | 處理中(等待檢查申報資料) | 資料檢核失敗 | 檔案傳送失敗 | 附件檔轉檔失敗 | 影像檔轉檔失敗 | 電子病歷檔轉檔失敗 | 申請檔案檢核失敗 | 申請檔案未備齊 | 已受理 | 審查中 | 審畢結果
Binding: NHI-健保事前審查-案件受理狀態值集 (required)
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..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 Claim item instance identifier
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 受理審查案件核定註記。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件
Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
ClaimResponse.item.adjudication.reason.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.adjudication.reason.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.adjudication.reason.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.adjudication.reason.text This element must be supported. This element is included in summaries. 0..1 string 核定意見
ClaimResponse.item.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.adjudication.value 0..1 decimal Non-monetary value
ClaimResponse.item.detail 1..* 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 請填寫對應的Claim.item.sequence
ClaimResponse.item.detail.noteNumber 0..* positiveInt Applicable note numbers
ClaimResponse.item.detail.adjudication 1..* BackboneElement Detail level adjudication details
ClaimResponse.item.detail.adjudication.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.extension 0..* Extension Additional content defined by implementations
ClaimResponse.item.detail.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.detail.adjudication.category 1..1 CodeableConcept 【因FHIR設計而需必填】
Binding: AdjudicationValueCodes (example): The adjudication codes.
ClaimResponse.item.detail.adjudication.category.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.category.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.detail.adjudication.category.coding This element is included in summaries. 0..* Coding Code defined by a terminology system
ClaimResponse.item.detail.adjudication.category.coding.id 0..1 string Unique id for inter-element referencing
ClaimResponse.item.detail.adjudication.category.coding.extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
ClaimResponse.item.detail.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.detail.adjudication.category.coding.version This element is included in summaries. 0..1 string Version of the system - if relevant
ClaimResponse.item.detail.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.detail.adjudication.category.coding.display This element is included in summaries. 0..1 string Representation defined by the system
ClaimResponse.item.detail.adjudication.category.coding.userSelected This element is included in summaries. 0..1 boolean If this coding was chosen directly by the user
ClaimResponse.item.detail.adjudication.category.text This element is included in summaries. 0..1 string Plain text representation of the concept
ClaimResponse.item.detail.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.detail.adjudication.amount 0..1 Money Monetary amount
ClaimResponse.item.detail.adjudication.value This element must be supported. 1..1 decimal 個別醫令核定數量
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.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📍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.disposition Base required NHI-健保事前審查-案件受理狀態值集 📦1.2.8 This IG
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-受理審查案件核定註記值集 📦1.2.8 This IG
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.detail.​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
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()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

以下概述了此Profile所需的RESTful FHIR互動功能。有關TWPAS支援的RESTful互動功能的完整清單，請參閱TWPAS Server能力聲明。

建議應該支援以下查詢參數：

  1. 必須（SHALL） 支援透過查詢參數 adjudication-reason 查詢所有ClaimResponse：
    (如何透過token查詢)
    GET [base]/ClaimResponse?adjudication-reason=[code]

    例子：
    (1) GET [base]/ClaimResponse?adjudication-reason=1

  2. 必須（SHALL） 支援透過查詢參數 identifier 查詢所有ClaimResponse：
    (如何透過token查詢)
    GET [base]/ClaimResponse?identifier=[code]

    例子：
    (1) GET [base]/ClaimResponse?identifier=20240831010109051701

  3. 必須（SHALL） 支援透過查詢參數 request.patient.name 查詢所有ClaimResponse：
    (如何透過reference查詢)
    (如何透過string查詢)
    GET [base]/ClaimResponse?request.patient.name=[姓名]

    例子：
    (1) GET [base]/ClaimResponse?request.patient.name=王大明

  4. 必須（SHALL） 支援透過查詢參數 request.patient.identifier 查詢所有ClaimResponse：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?request.patient.identifier=[code]

    例子：
    (1) GET [base]/ClaimResponse?request.patient.identifier=A123456789

  5. 必須（SHALL） 支援透過查詢參數 request.identifier 查詢所有ClaimResponse：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?request.identifier=[code]

    例子：
    (1) GET [base]/ClaimResponse?request.identifier=20240831010109051701

  6. 必須（SHALL） 支援透過查詢參數 request.func-type.service-type 查詢所有ClaimResponse：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?request.func-type.service-type={system|}[code]

    例子：
    (1) GET [base]/ClaimResponse?request.func-type.service-type=AJ
    (2) GET [base]/ClaimResponse?request.func-type.service-type=https://twcore.mohw.gov.tw/ig/twcore/CodeSystem/medical-consultation-department-nhi-tw|AJ

  7. 必須（SHALL） 支援透過查詢參數 created 及 disposition查詢所有ClaimResponse：
    (如何透過date查詢)
    (如何透過string查詢)
    GET [base]/ClaimResponse?created={gt|lt|ge|le}[date]{&created={gt|lt|ge|le}[date]}&disposition=[已受理|審畢結果]

    例子：
    (1) GET [base]/ClaimResponse?created=gt2024-08-01&created=lt2024-08-24&disposition=審畢結果

  8. 必須（SHALL） 支援透過查詢參數 requestor.identifier 查詢所有ClaimResponse：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?requestor.identifier=[code]

    例子：
    (1) GET [base]/ClaimResponse?requestor.identifier=0101090517

  9. 必須（SHALL） 支援透過查詢參數 request._lastUpdated 及 _include 查詢所有ClaimResponse及Claim：
    (如何透過reference查詢)
    (如何透過date查詢)
    GET [base]/ClaimResponse?request._lastUpdated={gt|lt|ge|le}[date]{&request._lastUpdated={gt|lt|ge|le}[date]&_include=ClaimResponse:request

    例子：
    (1) GET [base]/ClaimResponse?request._lastUpdated=gt2026-10-01T14:17&_include=ClaimResponse:request

  10. 必須（SHALL） 支援透過查詢參數 request.patient.identifier 及 request._lastUpdated 及 _include 查詢所有ClaimResponse及Claim：
    (如何透過reference查詢)
    (如何透過token查詢)
    (如何透過date查詢)
    GET [base]/ClaimResponse?request.patient.identifier=[code]&request._lastUpdated={gt|lt|ge|le}[date]{&request._lastUpdated={gt|lt|ge|le}[date]&_include=ClaimResponse:request

    例子：
    (1) GET [base]/ClaimResponse?request.patient.identifier=A123456789&request._lastUpdated=gt2026-10-01&_include=ClaimResponse:request

  11. 必須（SHALL） 支援透過查詢參數 request.id 及 _include 查詢所有ClaimResponse及Claim：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?request=Claim/[id]&_include=ClaimResponse:request
    例子：
    (1) GET [base]/ClaimResponse?request=Claim/2025021200111484&_include=ClaimResponse:request

  12. 必須（SHALL） 支援透過查詢參數 request.identifier 及 _include 查詢所有ClaimResponse及Claim：
    (如何透過reference查詢)
    (如何透過token查詢)
    GET [base]/ClaimResponse?request.identifier=[code]&_include=ClaimResponse:request
    例子：
    (1) GET [base]/ClaimResponse?request.identifier=FHR3501200000_2016101000000001.JSON&_include=ClaimResponse:request

  13. 必須（SHALL） 支援透過查詢參數 identifier 及 _include 查詢所有ClaimResponse及Claim：
    (如何透過token查詢)
    (如何透過reference查詢)
    GET [base]/ClaimResponse?identifier=[code]&_include=ClaimResponse:request
    例子：
    (1) GET [base]/ClaimResponse?identifier=202409301000002&_include=ClaimResponse:request