Belgian MyCareNet Profiles
2.0.0 - STU Belgium flag

This page is part of the HL7 Belgium FHIR Implementation Guide - MyCareNet profiles (v2.0.0: Trial Use) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, 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: 2.0.0
Active as of 2023-04-27 Computable Name: BeMyCareNetEagreementClaimResponse

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

Usage:

Formal Views of Profile Content

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

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id S1..1idLogical id of this artifact
... meta S1..1MetaMetadata about the resource
.... profile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
... status S1..1codeactive | cancelled | draft | entered-in-error
.... coding 1..1CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
... subType S1..1CodeableConceptMore granular claim type
.... coding 1..1CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code 1..1codeSymbol in syntax defined by the system
... use S1..1codeclaim | preauthorization | predetermination
... patient S1..1Reference(Patient core BE profile)The recipient of the products and services
... created S1..1dateTimeResponse creation date
... insurer S1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... outcome S1..1codequeued | complete | error | partial
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... start 1..1dateTimeStarting time with inclusive boundary
... item
.... adjudication S1..1BackboneElementAdjudication details
..... category
...... coding 1..1CodingCode defined by a terminology system
....... system 1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code 1..1codeSymbol in syntax defined by the system
..... reason
...... coding 1..1CodingCode defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... system 1..1uriIdentity of the terminology system
....... code 1..1codeSymbol in syntax defined by the system
... addItem S0..*BackboneElementInsurer added line items
.... itemSequence S1..1positiveIntItem sequence number
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding 1..1CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
...... code 1..1codeSymbol in syntax defined by the system
.... adjudication S1..*Added items adjudication

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClaimResponse.item.adjudication.reason.codingextensibleBeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

IdGradePath(s)DetailsRequirements
be-rule-eagreementclaimresponse-1errorClaimResponsepreAuthPeriod 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-2errorClaimResponseCreated SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
: ClaimResponse.created.toString().length()=25
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id SΣ1..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... profile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
... subType S1..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code Σ1..1codeSymbol in syntax defined by the system
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ1..1Reference(Patient core BE profile)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... start ΣC1..1dateTimeStarting time with inclusive boundary
... item 0..*BackboneElementAdjudication for claim line items
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... adjudication S1..1BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... coding Σ1..1CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code Σ1..1codeSymbol in syntax defined by the system
... addItem S0..*BackboneElementInsurer added line items
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S1..1positiveIntItem sequence number
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... adjudication S1..*See adjudication (ClaimResponse)Added items adjudication

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredUse
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

IdGradePath(s)DetailsRequirements
be-rule-eagreementclaimresponse-1errorClaimResponsepreAuthPeriod 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-2errorClaimResponseCreated SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
: ClaimResponse.created.toString().length()=25
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id SΣ1..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subType S1..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ1..1Reference(Patient core BE profile)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣC1..1dateTimeStarting time with inclusive boundary
.... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..1BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ1..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ1..1CodingCode defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ1..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem S0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S1..1positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..*See adjudication (ClaimResponse)Added items adjudication
.... detail 0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClaimResponse.meta.securityextensibleAll Security Labels
ClaimResponse.meta.tagexampleCommonTags
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredUse
ClaimResponse.requestor.typeextensibleResourceType
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
ClaimResponse.item.adjudication.reason.codingextensibleBeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.codeexampleAdjudication Error Codes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id S1..1idLogical id of this artifact
... meta S1..1MetaMetadata about the resource
.... profile 1..1canonical(StructureDefinition)Profiles this resource claims to conform to
... status S1..1codeactive | cancelled | draft | entered-in-error
.... coding 1..1CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
..... code 1..1codeSymbol in syntax defined by the system
... subType S1..1CodeableConceptMore granular claim type
.... coding 1..1CodingCode defined by a terminology system
..... system 1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code 1..1codeSymbol in syntax defined by the system
... use S1..1codeclaim | preauthorization | predetermination
... patient S1..1Reference(Patient core BE profile)The recipient of the products and services
... created S1..1dateTimeResponse creation date
... insurer S1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... outcome S1..1codequeued | complete | error | partial
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... start 1..1dateTimeStarting time with inclusive boundary
... item
.... adjudication S1..1BackboneElementAdjudication details
..... category
...... coding 1..1CodingCode defined by a terminology system
....... system 1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code 1..1codeSymbol in syntax defined by the system
..... reason
...... coding 1..1CodingCode defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... system 1..1uriIdentity of the terminology system
....... code 1..1codeSymbol in syntax defined by the system
... addItem S0..*BackboneElementInsurer added line items
.... itemSequence S1..1positiveIntItem sequence number
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding 1..1CodingCode defined by a terminology system
...... system 1..1uriIdentity of the terminology system
...... code 1..1codeSymbol in syntax defined by the system
.... adjudication S1..*Added items adjudication

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClaimResponse.item.adjudication.reason.codingextensibleBeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

IdGradePath(s)DetailsRequirements
be-rule-eagreementclaimresponse-1errorClaimResponsepreAuthPeriod 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-2errorClaimResponseCreated SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
: ClaimResponse.created.toString().length()=25

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id SΣ1..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... profile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
..... code Σ1..1codeSymbol in syntax defined by the system
... subType S1..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

.... coding Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... code Σ1..1codeSymbol in syntax defined by the system
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ1..1Reference(Patient core BE profile)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... start ΣC1..1dateTimeStarting time with inclusive boundary
... item 0..*BackboneElementAdjudication for claim line items
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... adjudication S1..1BackboneElementAdjudication details
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... coding Σ1..1CodingCode defined by a terminology system
....... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... code Σ1..1codeSymbol in syntax defined by the system
... addItem S0..*BackboneElementInsurer added line items
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S1..1positiveIntItem sequence number
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... coding Σ1..1CodingCode defined by a terminology system
...... system Σ1..1uriIdentity of the terminology system
...... code Σ1..1codeSymbol in syntax defined by the system
.... adjudication S1..*See adjudication (ClaimResponse)Added items adjudication

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredUse
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

IdGradePath(s)DetailsRequirements
be-rule-eagreementclaimresponse-1errorClaimResponsepreAuthPeriod 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-2errorClaimResponseCreated SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
: ClaimResponse.created.toString().length()=25
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse C0..*ClaimResponseResponse to a claim predetermination or preauthorization
be-rule-eagreementclaimresponse-1: preAuthPeriod start and end SHALL be YYYY-MM-DD
be-rule-eagreementclaimresponse-2: Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz
... id SΣ1..1idLogical id of this artifact
... meta SΣ1..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..1canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!SΣ1..1codeactive | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type SΣ1..1CodeableConceptMore granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subType S1..1CodeableConceptMore granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..1CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codeSymbol in syntax defined by the system
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... use SΣ1..1codeclaim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient SΣ1..1Reference(Patient core BE profile)The recipient of the products and services
... created SΣ1..1dateTimeResponse creation date
... insurer SΣ1..1Reference(Organisation core BE profile)Party responsible for reimbursement
... requestor S1..1Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)Party responsible for the claim
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... outcome SΣ1..1codequeued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.

... disposition 0..1stringDisposition Message
... preAuthRef S1..1stringPreauthorization reference
... preAuthPeriod S0..1PeriodPreauthorization reference effective period
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... start ΣC1..1dateTimeStarting time with inclusive boundary
.... end ΣC0..1dateTimeEnd time with inclusive boundary, if not ongoing
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item 0..*BackboneElementAdjudication for claim line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..1BackboneElementAdjudication details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... category 1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ1..1CodingCode defined by a terminology system
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ1..1uriIdentity of the terminology system
Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.

...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ1..1CodingCode defined by a terminology system
Binding: ValueSet adjudication reason (extensible)
....... id 0..1stringUnique id for inter-element referencing
....... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ1..1uriIdentity of the terminology system
....... version Σ0..1stringVersion of the system - if relevant
....... code Σ1..1codeSymbol in syntax defined by the system
....... display Σ0..1stringRepresentation defined by the system
....... userSelected Σ0..1booleanIf this coding was chosen directly by the user
...... text Σ0..1stringPlain text representation of the concept
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementAdjudication for claim details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Detail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*See adjudication (ClaimResponse)Subdetail level adjudication details
... addItem S0..*BackboneElementInsurer added line items
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence S1..1positiveIntItem sequence number
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: ValueSet product or service (extensible)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
..... text Σ0..1stringPlain text representation of the concept
.... modifier 0..*CodeableConceptService/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..*CodeableConceptProgram the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.


.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.

..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.

.... subSite 0..*CodeableConceptAnatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.


.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication S1..*See adjudication (ClaimResponse)Added items adjudication
.... detail 0..*BackboneElementInsurer added line details
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

..... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
..... subDetail 0..*BackboneElementInsurer added line items
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
...... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.

...... modifier 0..*CodeableConceptService/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..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*See adjudication (ClaimResponse)Added items detail adjudication
... adjudication 0..*See adjudication (ClaimResponse)Header-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... category Σ1..1CodeableConceptType of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.

.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... type 1..1CodeableConceptPartial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.

.... adjustment 0..1MoneyPayment adjustment for non-claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.

.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptFunds reserved status
Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).

... formCode 0..1CodeableConceptPrinted form identifier
Binding: Form Codes (example): The forms codes.

... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results
... error 0..*BackboneElementProcessing errors
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClaimResponse.meta.securityextensibleAll Security Labels
ClaimResponse.meta.tagexampleCommonTags
ClaimResponse.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredFinancialResourceStatusCodes
ClaimResponse.typeextensibleClaimTypeCodes
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
ClaimResponse.userequiredUse
ClaimResponse.requestor.typeextensibleResourceType
ClaimResponse.outcomerequiredClaimProcessingCodes
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
ClaimResponse.item.adjudication.reason.codingextensibleBeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrServiceextensibleBeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)
ClaimResponse.addItem.modifierexampleModifierTypeCodes
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
ClaimResponse.addItem.subSiteexampleSurfaceCodes
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
ClaimResponse.total.categoryexampleAdjudicationValueCodes
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserveexampleFunds Reservation Codes
ClaimResponse.formCodeexampleForm Codes
ClaimResponse.processNote.typerequiredNoteType
ClaimResponse.processNote.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.codeexampleAdjudication Error Codes

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

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