Belgian MyCareNet Profiles
2.1.2 - STU Belgium flag

Belgian MyCareNet Profiles, published by eHealth Platform. This guide is not an authorized publication; it is the continuous build for version 2.1.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7-be/mycarenet/ and changes regularly. See the Directory of published versions

Resource Profile: MyCareNet eAgreement Claim Response BE profile

Official URL: https://www.ehealth.fgov.be/standards/fhir/mycarenet/StructureDefinition/be-eagreementclaimresponse Version: 2.1.2
Standards status: Trial-use Maturity Level: 1 Computable Name: BeMyCareNetEagreementClaimResponse

Claimresponse profile for use in the different eAgreement flows from MyCareNet.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
..... code Σ 1..1 code Symbol in syntax defined by the system
... subType S 1..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code Σ 1..1 code Symbol in syntax defined by the system
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... start ΣC 1..1 dateTime Starting time with inclusive boundary
... item 0..* BackboneElement Adjudication for claim line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..1 BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... coding Σ 1..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code Σ 1..1 code Symbol in syntax defined by the system
... addItem S 0..* BackboneElement Insurer added line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Item sequence number
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding Σ 1..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... adjudication S 1..* See adjudication (ClaimResponse) Added items adjudication

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.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.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG

Constraints

Id Grade Path(s) Description Expression
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25
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: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id S 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
... status S 1..1 code active | cancelled | draft | entered-in-error
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
..... code 1..1 code Symbol in syntax defined by the system
... subType S 1..1 CodeableConcept More granular claim type
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code 1..1 code Symbol in syntax defined by the system
... use S 1..1 code claim | preauthorization | predetermination
... patient S 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... outcome S 1..1 code queued | complete | error | partial
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... start 1..1 dateTime Starting time with inclusive boundary
... item
.... adjudication S 1..1 BackboneElement Adjudication details
..... category
...... coding 1..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code 1..1 code Symbol in syntax defined by the system
..... reason
...... coding 1..1 Coding Code defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... system 1..1 uri Identity of the terminology system
....... code 1..1 code Symbol in syntax defined by the system
... addItem S 0..* BackboneElement Insurer added line items
.... itemSequence S 1..1 positiveInt Item sequence number
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding 1..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
.... adjudication S 1..* Added items adjudication

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.item.adjudication.​reason.coding Base extensible ValueSet adjudication reason 📦2.1.2 This IG
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG

Constraints

Id Grade Path(s) Description Expression
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 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
.... 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 BindingsPurpose
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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... 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 1..1 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 1..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... 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
... subType S 1..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... 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 1..1 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 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... 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
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... request Σ 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣC 1..1 dateTime Starting time with inclusive boundary
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item 0..* BackboneElement Adjudication for claim line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication S 1..1 BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... 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 1..1 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 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
....... 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 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason 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 1..1 Coding Code defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... 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 1..1 uri Identity of the terminology system
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
....... 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
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem S 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 S 1..1 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: ValueSet product or service (extensible)
..... 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 1..1 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 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... 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
.... 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 S 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 BindingsPurpose
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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.requestor.​type Base extensible ResourceType 📍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 example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason.coding Base extensible ValueSet adjudication reason 📦2.1.2 This IG
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG
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
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 1..1 Meta Metadata about the resource
.... profile Σ 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
..... code Σ 1..1 code Symbol in syntax defined by the system
... subType S 1..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... coding Σ 1..1 Coding Code defined by a terminology system
..... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code Σ 1..1 code Symbol in syntax defined by the system
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... start ΣC 1..1 dateTime Starting time with inclusive boundary
... item 0..* BackboneElement Adjudication for claim line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..1 BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... coding Σ 1..1 Coding Code defined by a terminology system
....... system Σ 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code Σ 1..1 code Symbol in syntax defined by the system
... addItem S 0..* BackboneElement Insurer added line items
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Item sequence number
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding Σ 1..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... adjudication S 1..* See adjudication (ClaimResponse) Added items adjudication

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.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.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG

Constraints

Id Grade Path(s) Description Expression
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25
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: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id S 1..1 id Logical id of this artifact
... meta S 1..1 Meta Metadata about the resource
.... profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to
... status S 1..1 code active | cancelled | draft | entered-in-error
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
..... code 1..1 code Symbol in syntax defined by the system
... subType S 1..1 CodeableConcept More granular claim type
.... coding 1..1 Coding Code defined by a terminology system
..... system 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code 1..1 code Symbol in syntax defined by the system
... use S 1..1 code claim | preauthorization | predetermination
... patient S 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... reference 1..1 string Literal reference, Relative, internal or absolute URL
... outcome S 1..1 code queued | complete | error | partial
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... start 1..1 dateTime Starting time with inclusive boundary
... item
.... adjudication S 1..1 BackboneElement Adjudication details
..... category
...... coding 1..1 Coding Code defined by a terminology system
....... system 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code 1..1 code Symbol in syntax defined by the system
..... reason
...... coding 1..1 Coding Code defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... system 1..1 uri Identity of the terminology system
....... code 1..1 code Symbol in syntax defined by the system
... addItem S 0..* BackboneElement Insurer added line items
.... itemSequence S 1..1 positiveInt Item sequence number
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding 1..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
.... adjudication S 1..* Added items adjudication

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.item.adjudication.​reason.coding Base extensible ValueSet adjudication reason 📦2.1.2 This IG
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG

Constraints

Id Grade Path(s) Description Expression
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: be-rule-eagreementclaimresponse-1, be-rule-eagreementclaimresponse-2
... id SΣ 1..1 id Logical id of this artifact
... meta SΣ 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
.... 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 BindingsPurpose
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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... 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 1..1 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 1..1 uri Identity of the terminology system
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... 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
... subType S 1..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... 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 1..1 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 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 1..1 code Symbol in syntax defined by the system
..... 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
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(BePatient(2.1.2)) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(BeOrganization(2.1.2)) Party responsible for reimbursement
... requestor S 1..1 Reference(BeOrganization(2.1.2) | BePractitioner(2.1.2) | BePractitionerRole(2.1.2)) Party responsible for the claim
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... request Σ 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Disposition Message
... preAuthRef S 1..1 string Preauthorization reference
... preAuthPeriod S 0..1 Period Preauthorization reference effective period
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣC 1..1 dateTime Starting time with inclusive boundary
.... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item 0..* BackboneElement Adjudication for claim line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication S 1..1 BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... 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 1..1 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 1..1 uri Identity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
....... 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 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason 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 1..1 Coding Code defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... 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 1..1 uri Identity of the terminology system
....... version Σ 0..1 string Version of the system - if relevant
....... code Σ 1..1 code Symbol in syntax defined by the system
....... 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
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Adjudication for claim details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem S 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 S 1..1 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: ValueSet product or service (extensible)
..... 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 1..1 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 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... 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
.... 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 S 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 BindingsPurpose
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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.requestor.​type Base extensible ResourceType 📍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 example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason.coding Base extensible ValueSet adjudication reason 📦2.1.2 This IG
ClaimResponse.addItem.​productOrService Base extensible ValueSet product or service 📦2.1.2 This IG
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
be-rule-eagreementclaimresponse-1 error ClaimResponse preAuthPeriod start and end SHALL be YYYY-MM-DD (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2 error ClaimResponse Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz ClaimResponse.created.toString().length()=25
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()

 

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