SIL HIE Implementation Guide
0.1.0 - sil-hie-active

SIL HIE Implementation Guide, published by Kathurima Kimathi. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/savannahghi/hie-fhir-ig-profile/ and changes regularly. See the Directory of published versions

Resource Profile: HIE ClaimResponse

Official URL: https://nshr.dha.go.ke/fhir/StructureDefinition/hie-claimresponse Version: 0.1.0
Active as of 2025-11-25 Computable Name: HIEClaimResponse

R4B ClaimResponse constrained for HIE payer adjudication exchanges. Focus on request linkage, parties, outcome, adjudication details, totals, and payment.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for a claim response
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... type Σ 1..1 HIECodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request SΣ 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: RemittanceOutcome (required): The result of the claim processing.
... payeeType 0..1 HIECodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item S 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 1..1 Money Monetary amount
.... detail 1..* BackboneElement Adjudication for claim details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... adjudication 1..* BackboneElement Detail level adjudication details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
... total SΣ 1..* BackboneElement Adjudication totals
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 1..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 HIECodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustmentReason 0..1 HIECodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... amount 1..1 Money Payable amount after adjustment
... fundsReserve 0..1 HIECodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 HIECodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* BackboneElement Patient insurance information
.... 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 HIEReference(Coverage) Insurance information
.... claimResponse 0..1 HIEReference(HIE ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.3.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.use Base required Use 📍4.3.0 FHIR Std.
ClaimResponse.outcome Base required RemittanceOutcome 📍4.3.0 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.3.0 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.3.0 FHIR Std.

Constraints

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

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... identifier S 1..* Identifier Business Identifier for a claim response
.... use 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system 1..1 uri The namespace for the identifier value
.... value S 1..1 string The value that is unique
.... assigner S 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status S 1..1 code active | cancelled | draft | entered-in-error
... type 1..1 HIECodeableConcept More granular claim type
... patient S 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request S 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome S 1..1 code queued | complete | error | partial
... payeeType 0..1 HIECodeableConcept Party to be paid any benefits payable
... item S 1..* BackboneElement Adjudication for claim line items
.... adjudication
..... category 1..1 HIECodeableConcept Type of adjudication information
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... amount 1..1 Money Monetary amount
.... detail 1..* BackboneElement Adjudication for claim details
..... adjudication 1..* BackboneElement Detail level adjudication details
...... category 1..1 HIECodeableConcept Type of adjudication information
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... subDetail
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... category 1..1 HIECodeableConcept Type of adjudication information
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
... addItem
.... provider 0..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Authorized providers
.... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
.... modifier 0..* HIECodeableConcept Service/Product billing modifiers
.... programCode 0..* HIECodeableConcept Program the product or service is provided under
.... bodySite 0..1 HIECodeableConcept Anatomical location
.... subSite 0..* HIECodeableConcept Anatomical sub-location
.... adjudication 1..* BackboneElement Added items adjudication
..... category 1..1 HIECodeableConcept Type of adjudication information
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
.... detail
..... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
..... modifier 0..* HIECodeableConcept Service/Product billing modifiers
..... adjudication 1..* BackboneElement Added items detail adjudication
...... category 1..1 HIECodeableConcept Type of adjudication information
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... subDetail
...... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
...... modifier 0..* HIECodeableConcept Service/Product billing modifiers
...... adjudication 1..* BackboneElement Added items detail adjudication
....... category 1..1 HIECodeableConcept Type of adjudication information
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
... total S 1..* BackboneElement Adjudication totals
.... category 1..1 HIECodeableConcept Type of adjudication information
... payment 1..1 BackboneElement Payment Details
.... type 1..1 HIECodeableConcept Partial or complete payment
.... adjustmentReason 0..1 HIECodeableConcept Explanation for the adjustment
... fundsReserve 0..1 HIECodeableConcept Funds reserved status
... formCode 0..1 HIECodeableConcept Printed form identifier
... processNote
.... language 0..1 HIECodeableConcept Language of the text
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* BackboneElement Patient insurance information
.... coverage 1..1 HIEReference(Coverage) Insurance information
.... claimResponse 0..1 HIEReference(HIE ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): IETF language tag
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
Constraints: dom-r4b
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for a claim response
.... id 0..1 id Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 HIECodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request SΣ 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: RemittanceOutcome (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 HIECodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item S 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 1..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 1..* 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..* 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
...... 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 1..* BackboneElement Subdetail 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
....... amount 0..1 Money Monetary amount
....... value 0..1 decimal Non-monetary value
... 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..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Authorized providers
.... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* HIECodeableConcept 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..* HIECodeableConcept 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(4.3.0) 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 HIECodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* HIECodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Added items 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
..... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... 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 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* HIECodeableConcept 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(4.3.0) 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..* BackboneElement Added items detail 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
...... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monetary value
..... 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 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* HIECodeableConcept 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(4.3.0) 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..* BackboneElement Added items detail 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
....... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
....... amount 0..1 Money Monetary amount
....... value 0..1 decimal Non-monetary value
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total SΣ 1..* 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 1..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 HIECodeableConcept 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 HIECodeableConcept 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 HIECodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 HIECodeableConcept 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 HIECodeableConcept Language of the text
Binding: CommonLanguages (preferred): IETF language tag
Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* 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 HIEReference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 HIEReference(HIE 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.language Base preferred Common Languages 📍4.3.0 FHIR Std.
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.3.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.3.0 FHIR Std.
ClaimResponse.use Base required Use 📍4.3.0 FHIR Std.
ClaimResponse.outcome Base required RemittanceOutcome 📍4.3.0 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​subDetail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.3.0 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.3.0 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.3.0 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.3.0 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.3.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where(((id.exists() and ('#'+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(uri) = '#').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()
dom-r4b warning ClaimResponse.contained Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for a claim response
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... type Σ 1..1 HIECodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request SΣ 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: RemittanceOutcome (required): The result of the claim processing.
... payeeType 0..1 HIECodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item S 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 1..1 Money Monetary amount
.... detail 1..* BackboneElement Adjudication for claim details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Claim detail instance identifier
..... adjudication 1..* BackboneElement Detail level adjudication details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
... total SΣ 1..* BackboneElement Adjudication totals
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 1..1 BackboneElement Payment Details
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 HIECodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustmentReason 0..1 HIECodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... amount 1..1 Money Payable amount after adjustment
... fundsReserve 0..1 HIECodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 HIECodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* BackboneElement Patient insurance information
.... 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 HIEReference(Coverage) Insurance information
.... claimResponse 0..1 HIEReference(HIE ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.3.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.use Base required Use 📍4.3.0 FHIR Std.
ClaimResponse.outcome Base required RemittanceOutcome 📍4.3.0 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.3.0 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.3.0 FHIR Std.

Constraints

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

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... identifier S 1..* Identifier Business Identifier for a claim response
.... use 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system 1..1 uri The namespace for the identifier value
.... value S 1..1 string The value that is unique
.... assigner S 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status S 1..1 code active | cancelled | draft | entered-in-error
... type 1..1 HIECodeableConcept More granular claim type
... patient S 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created S 1..1 dateTime Response creation date
... insurer S 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request S 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome S 1..1 code queued | complete | error | partial
... payeeType 0..1 HIECodeableConcept Party to be paid any benefits payable
... item S 1..* BackboneElement Adjudication for claim line items
.... adjudication
..... category 1..1 HIECodeableConcept Type of adjudication information
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... amount 1..1 Money Monetary amount
.... detail 1..* BackboneElement Adjudication for claim details
..... adjudication 1..* BackboneElement Detail level adjudication details
...... category 1..1 HIECodeableConcept Type of adjudication information
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... subDetail
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... category 1..1 HIECodeableConcept Type of adjudication information
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
... addItem
.... provider 0..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Authorized providers
.... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
.... modifier 0..* HIECodeableConcept Service/Product billing modifiers
.... programCode 0..* HIECodeableConcept Program the product or service is provided under
.... bodySite 0..1 HIECodeableConcept Anatomical location
.... subSite 0..* HIECodeableConcept Anatomical sub-location
.... adjudication 1..* BackboneElement Added items adjudication
..... category 1..1 HIECodeableConcept Type of adjudication information
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
.... detail
..... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
..... modifier 0..* HIECodeableConcept Service/Product billing modifiers
..... adjudication 1..* BackboneElement Added items detail adjudication
...... category 1..1 HIECodeableConcept Type of adjudication information
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
..... subDetail
...... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
...... modifier 0..* HIECodeableConcept Service/Product billing modifiers
...... adjudication 1..* BackboneElement Added items detail adjudication
....... category 1..1 HIECodeableConcept Type of adjudication information
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
... total S 1..* BackboneElement Adjudication totals
.... category 1..1 HIECodeableConcept Type of adjudication information
... payment 1..1 BackboneElement Payment Details
.... type 1..1 HIECodeableConcept Partial or complete payment
.... adjustmentReason 0..1 HIECodeableConcept Explanation for the adjustment
... fundsReserve 0..1 HIECodeableConcept Funds reserved status
... formCode 0..1 HIECodeableConcept Printed form identifier
... processNote
.... language 0..1 HIECodeableConcept Language of the text
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* BackboneElement Patient insurance information
.... coverage 1..1 HIEReference(Coverage) Insurance information
.... claimResponse 0..1 HIEReference(HIE ClaimResponse) Adjudication results

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): IETF language tag
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
Constraints: dom-r4b
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* Identifier Business Identifier for a claim response
.... id 0..1 id Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 HIECodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 HIEReference(HIE Patient) The recipient of the products and services
... created SΣ 1..1 dateTime Response creation date
... insurer SΣ 1..1 HIEReference(HIE Organization) Party responsible for reimbursement
... requestor 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Party responsible for the claim
... request SΣ 1..1 HIEReference(HIE Claim) Id of resource triggering adjudication
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: RemittanceOutcome (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 HIECodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item S 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 1..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... detail 1..* 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..* 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
...... 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 1..* BackboneElement Subdetail 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
....... amount 0..1 Money Monetary amount
....... value 0..1 decimal Non-monetary value
... 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..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Authorized providers
.... productOrService 1..1 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* HIECodeableConcept 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..* HIECodeableConcept 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(4.3.0) 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 HIECodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* HIECodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Added items 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
..... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 0..1 Money Monetary amount
..... value 0..1 decimal Non-monetary value
.... 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 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* HIECodeableConcept 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(4.3.0) 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..* BackboneElement Added items detail 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
...... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
...... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
...... amount 0..1 Money Monetary amount
...... value 0..1 decimal Non-monetary value
..... 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 HIECodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* HIECodeableConcept 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(4.3.0) 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..* BackboneElement Added items detail 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
....... category 1..1 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
....... reason 0..1 HIECodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
....... amount 0..1 Money Monetary amount
....... value 0..1 decimal Non-monetary value
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total SΣ 1..* 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 HIECodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 1..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 HIECodeableConcept 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 HIECodeableConcept 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 HIECodeableConcept Funds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 HIECodeableConcept 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 HIECodeableConcept Language of the text
Binding: CommonLanguages (preferred): IETF language tag
Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* HIEReference(CommunicationRequest) Request for additional information
... insurance 1..* 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 HIEReference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 HIEReference(HIE 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.language Base preferred Common Languages 📍4.3.0 FHIR Std.
ClaimResponse.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
ClaimResponse.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.3.0 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.3.0 FHIR Std.
ClaimResponse.use Base required Use 📍4.3.0 FHIR Std.
ClaimResponse.outcome Base required RemittanceOutcome 📍4.3.0 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​subDetail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​adjudication.category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​adjudication.reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.adjudication.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.adjudication.​reason Base example Adjudication Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.3.0 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.3.0 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.3.0 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.3.0 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.3.0 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.3.0 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.3.0 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where(((id.exists() and ('#'+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(uri) = '#').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()
dom-r4b warning ClaimResponse.contained Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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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