臺灣健保事前審查實作指引
1.1.0 - 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 1.1.0 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: 1.1.0
Active as of 2025-12-17 | 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:

- Use this Profile: 免疫製劑事前審查-Bundle Immunologic Aagent TWPAS and 癌藥事前審查-Bundle TWPAS
- Examples for this Profile: ClaimResponse/self-assessment-example
- CapabilityStatements using this Profile: 臺灣事前審查-用戶端(TWPAS Client) and 臺灣事前審查-伺服端(TWPAS Server)

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.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
meta | Σ | 1..1 | Meta | Metadata about the resource
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 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。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 1..* | BackboneElement | Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
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-受理審查案件核定註記值集 | 📦1.1.0 | 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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
meta |  | 1..1 | Meta | Metadata about the resource
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
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
status |  | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active
type |  | 1..1 | CodeableConcept | More granular claim type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient |  | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S | 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。
insurer |  | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
item |  | 1..* | BackboneElement | Adjudication for claim line items
adjudication |  |  |  |
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason |  | 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)
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-受理審查案件核定註記值集 | 📦1.1.0 | 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 | 📦1.1.0 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 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".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 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。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 1..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
reason |  | 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)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
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-受理審查案件核定註記值集 | 📦1.1.0 | 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 | 📦1.1.0 | 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()`

This structure is derived from ClaimResponse

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Patient-twpas)
- TW Core Organization Government (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-govt-twcore)

Extensions

This structure refers to these extensions:

- https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
meta | Σ | 1..1 | Meta | Metadata about the resource
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 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。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 1..* | BackboneElement | Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
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-受理審查案件核定註記值集 | 📦1.1.0 | 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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
meta |  | 1..1 | Meta | Metadata about the resource
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
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
status |  | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active
type |  | 1..1 | CodeableConcept | More granular claim type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient |  | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S | 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。
insurer |  | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
item |  | 1..* | BackboneElement | Adjudication for claim line items
adjudication |  |  |  |
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason |  | 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)
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-受理審查案件核定註記值集 | 📦1.1.0 | 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 | 📦1.1.0 | This IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 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".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:requestor | S | 1..* | Identifier | 審查委員身分證號 URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 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。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 1..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。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)
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | 審查結果數量，若申請案件類別為3時須填寫。
detail |  | 0..* | BackboneElement | Adjudication for claim details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
reason |  | 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)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..1 | positiveInt | Item sequence number
detailSequence |  | 0..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
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-受理審查案件核定註記值集 | 📦1.1.0 | 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 | 📦1.1.0 | 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()`

This structure is derived from ClaimResponse

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 4 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Patient-twpas)
- TW Core Organization Government (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-govt-twcore)

Extensions

This structure refers to these extensions:

- https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor

Other representations of profile: CSV, Excel, Schematron