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

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Resource Profile: MyCareNet eAgreement Claim Response BE profile

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

Usage:

• Use this Resource Profile: MyCareNet eAgreement Demand Reply Bundle BE profile

Formal Views of Profile Content

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

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

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	C	0..*	ClaimResponse	Response 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	S	1..1	id	Logical id of this artifact
meta	S	1..1	Meta	Metadata about the resource
profile		1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	1..1	CodeableConcept	More granular claim type
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
subType	S	1..1	CodeableConcept	More granular claim type
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
code		1..1	code	Symbol in syntax defined by the system
use	S	1..1	code	claim | preauthorization | predetermination
patient	S	1..1	Reference(Patient core BE profile)	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(Organisation core BE profile)	Party responsible for reimbursement
requestor	S	1..1	Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)	Party responsible for the claim
reference		1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	code	queued | complete | error | partial
preAuthRef	S	1..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
start		1..1	dateTime	Starting time with inclusive boundary
item
adjudication	S	1..1	BackboneElement	Adjudication details
category
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
code		1..1	code	Symbol in syntax defined by the system
reason
coding		1..1	Coding	Code defined by a terminology system Binding: ValueSet adjudication reason (extensible)
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
addItem	S	0..*	BackboneElement	Insurer added line items
itemSequence	S	1..1	positiveInt	Item sequence number
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ValueSet product or service (extensible)
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
adjudication	S	1..*		Added items adjudication
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
ClaimResponse.item.adjudication.reason.coding	extensible	BeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

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

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

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.item.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

Id	Grade	Path(s)	Details	Requirements
be-rule-eagreementclaimresponse-1	error	ClaimResponse	preAuthPeriod start and end SHALL be YYYY-MM-DD : (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2	error	ClaimResponse	Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz : ClaimResponse.created.toString().length()=25
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	C	0..*	ClaimResponse	Response 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	SΣ	1..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subType	S	1..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	SΣ	1..1	Reference(Patient core BE profile)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organisation core BE profile)	Party responsible for reimbursement
requestor	S	1..1	Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)	Party responsible for the claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef	S	1..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..1	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system Binding: ValueSet adjudication reason (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ValueSet product or service (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.meta.security	extensible	All Security Labels
ClaimResponse.meta.tag	example	CommonTags
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.requestor.type	extensible	ResourceType
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.item.adjudication.reason.coding	extensible	BeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 13 elements (11 nested mandatory elements)
Must-Support: 17 elements

Structures

This structure refers to these other structures:

• Patient core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-patient)
• Organisation core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-organization)
• Practitioner core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitioner)
• Practitioner role core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitionerrole)

Differential View

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	C	0..*	ClaimResponse	Response 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	S	1..1	id	Logical id of this artifact
meta	S	1..1	Meta	Metadata about the resource
profile		1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
status	S	1..1	code	active | cancelled | draft | entered-in-error
type	S	1..1	CodeableConcept	More granular claim type
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
subType	S	1..1	CodeableConcept	More granular claim type
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
code		1..1	code	Symbol in syntax defined by the system
use	S	1..1	code	claim | preauthorization | predetermination
patient	S	1..1	Reference(Patient core BE profile)	The recipient of the products and services
created	S	1..1	dateTime	Response creation date
insurer	S	1..1	Reference(Organisation core BE profile)	Party responsible for reimbursement
requestor	S	1..1	Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)	Party responsible for the claim
reference		1..1	string	Literal reference, Relative, internal or absolute URL
outcome	S	1..1	code	queued | complete | error | partial
preAuthRef	S	1..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
start		1..1	dateTime	Starting time with inclusive boundary
item
adjudication	S	1..1	BackboneElement	Adjudication details
category
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
code		1..1	code	Symbol in syntax defined by the system
reason
coding		1..1	Coding	Code defined by a terminology system Binding: ValueSet adjudication reason (extensible)
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
addItem	S	0..*	BackboneElement	Insurer added line items
itemSequence	S	1..1	positiveInt	Item sequence number
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ValueSet product or service (extensible)
coding		1..1	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system
code		1..1	code	Symbol in syntax defined by the system
adjudication	S	1..*		Added items adjudication
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
ClaimResponse.item.adjudication.reason.coding	extensible	BeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

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

Key Elements View

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

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.item.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)

Constraints

Id	Grade	Path(s)	Details	Requirements
be-rule-eagreementclaimresponse-1	error	ClaimResponse	preAuthPeriod start and end SHALL be YYYY-MM-DD : (ClaimResponse.preAuthPeriod.exists() implies ClaimResponse.preAuthPeriod.start.toString().length()=10) and (ClaimResponse.preAuthPeriod.end.exists() implies ClaimResponse.preAuthPeriod.end.toString().length()=10)
be-rule-eagreementclaimresponse-2	error	ClaimResponse	Created SHALL be YYYY-MM-DDThh:mm:ss+zz:zz : ClaimResponse.created.toString().length()=25
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
ClaimResponse	C	0..*	ClaimResponse	Response 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	SΣ	1..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		0..*	Identifier	Business Identifier for a claim response
status	?!SΣ	1..1	code	active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	SΣ	1..1	CodeableConcept	More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subType	S	1..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/agreement-types
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
use	SΣ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	SΣ	1..1	Reference(Patient core BE profile)	The recipient of the products and services
created	SΣ	1..1	dateTime	Response creation date
insurer	SΣ	1..1	Reference(Organisation core BE profile)	Party responsible for reimbursement
requestor	S	1..1	Reference(Organisation core BE profile | Practitioner core BE profile | Practitioner role core BE profile)	Party responsible for the claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
request	Σ	0..1	Reference(Claim)	Id of resource triggering adjudication
outcome	SΣ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef	S	1..1	string	Preauthorization reference
preAuthPeriod	S	0..1	Period	Preauthorization reference effective period
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		0..*	BackboneElement	Adjudication for claim line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Claim item instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..1	BackboneElement	Adjudication details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Required Pattern: https://www.ehealth.fgov.be/standards/fhir/mycarenet/CodeSystem/decision-values
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
reason		0..1	CodeableConcept	Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system Binding: ValueSet adjudication reason (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
amount		0..1	Money	Monetary amount
value		0..1	decimal	Non-monetary value
detail		0..*	BackboneElement	Adjudication for claim details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Claim detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem	S	0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	1..1	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: ValueSet product or service (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication	S	1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Header-level adjudication
total	Σ	0..*	BackboneElement	Adjudication totals
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Payment Details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment
amount		1..1	Money	Payable amount after adjustment
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Processing errors
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Item sequence number
detailSequence		0..1	positiveInt	Detail sequence number
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
ClaimResponse.meta.security	extensible	All Security Labels
ClaimResponse.meta.tag	example	CommonTags
ClaimResponse.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	FinancialResourceStatusCodes
ClaimResponse.type	extensible	ClaimTypeCodes
ClaimResponse.subType	example	ExampleClaimSubTypeCodes
ClaimResponse.use	required	Use
ClaimResponse.requestor.type	extensible	ResourceType
ClaimResponse.outcome	required	ClaimProcessingCodes
ClaimResponse.payeeType	example	Claim Payee Type Codes
ClaimResponse.item.adjudication.category	example	AdjudicationValueCodes
ClaimResponse.item.adjudication.reason	example	AdjudicationReasonCodes
ClaimResponse.item.adjudication.reason.coding	extensible	BeEAgreementAdjudicationReason
ClaimResponse.addItem.productOrService	extensible	BeProductOrServiceNihdiEAgreement (a valid code from CodeSystem NIHDIPhysiotherapyPathology)
ClaimResponse.addItem.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes
ClaimResponse.addItem.bodySite	example	OralSiteCodes
ClaimResponse.addItem.subSite	example	SurfaceCodes
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes
ClaimResponse.total.category	example	AdjudicationValueCodes
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve	example	Funds Reservation Codes
ClaimResponse.formCode	example	Form Codes
ClaimResponse.processNote.type	required	NoteType
ClaimResponse.processNote.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 13 elements (11 nested mandatory elements)
Must-Support: 17 elements

Structures

This structure refers to these other structures:

• Patient core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-patient)
• Organisation core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-organization)
• Practitioner core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitioner)
• Practitioner role core BE profile (https://www.ehealth.fgov.be/standards/fhir/core/StructureDefinition/be-practitionerrole)