FHIR Implementation Guide for ABDM
6.5.0 - active India flag

Banner

This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: ClaimResponse

Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/ClaimResponse Version: 6.5.0
Draft as of 2025-03-18 Computable Name: ClaimResponse

This profile represents application level adjudication outcomes, or an application level error, that occur as a result of processing a supplied Claim resource, which could be a functional corollary of a Claim, Predetermination, or Preauthorization.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: 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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


ele-1: All FHIR elements must have a @value or children
... patient Σ 1..1 Reference(Patient) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... request SΣ 0..1 Reference(Claim) Id of resource triggering adjudication
ele-1: All FHIR elements must have a @value or children
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... disposition S 0..1 string Disposition Message
ele-1: All FHIR elements must have a @value or children
... item S 0..* BackboneElement Adjudication for claim line items
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... itemSequence 1..1 positiveInt Claim item instance identifier
ele-1: All FHIR elements must have a @value or children
.... adjudication 1..* BackboneElement Adjudication details
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
ele-1: All FHIR elements must have a @value or children
... total SΣ 0..* BackboneElement Adjudication totals
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
.... amount Σ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Code (example): Specify type of document attached with as form.


ele-1: All FHIR elements must have a @value or children
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
ele-1: All FHIR elements must have a @value or children
... insurance S 0..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Insurance instance identifier
ele-1: All FHIR elements must have a @value or children
.... focal 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage S 1..1 Reference(Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
ele-1: All FHIR elements must have a @value or children
... error S 0..* BackboneElement Processing errors
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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()

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse ClaimResponse
... type 1..1 CodeableConcept More granular claim type
Binding: Claim Type (extensible)
... patient 1..1 Reference(Patient) The recipient of the products and services
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement
... request S 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome S 1..1 code queued | complete | error | partial
... disposition S 0..1 string Disposition Message
... item S 0..* BackboneElement Adjudication for claim line items
.... adjudication
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
... addItem
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
..... coding
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Program Code (example)
..... coding
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
.... detail
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
...... coding
....... system 1..1 uri Identity of the terminology system
....... code 1..1 code Symbol in syntax defined by the system
....... display 1..1 string Representation defined by the system
..... subDetail
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
....... coding
........ system 1..1 uri Identity of the terminology system
........ code 1..1 code Symbol in syntax defined by the system
........ display 1..1 string Representation defined by the system
... total S 0..* BackboneElement Adjudication totals
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Code (example): Specify type of document attached with as form.

... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... coverage S 1..1 Reference(Coverage) Insurance information
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error S 0..* BackboneElement Processing errors

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.addItem.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.programCodeexampleProgramCode (a valid code from Program Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code
from this IG
ClaimResponse.addItem.detail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
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 ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 1..1 CodeableConcept More granular claim type
Binding: Claim Type (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 1..1 Reference(Patient) The recipient of the products and services
... created Σ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request SΣ 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 S 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item S 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 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.

..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
..... 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 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 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 1..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: Program Code (example)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 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 1..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
.... 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 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: ProductorService (example)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 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 1..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.


..... 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: ProductorService (example)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... coding Σ 0..* Coding Code defined by a terminology system
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
........ system Σ 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 1..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.


...... 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 SΣ 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 Code (example): Specify type of document attached with as form.

... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance S 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 S 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error S 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..1 positiveInt Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.addItem.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleProgramCode (a valid code from Program Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code
from this IG
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: 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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


ele-1: All FHIR elements must have a @value or children
... patient Σ 1..1 Reference(Patient) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... request SΣ 0..1 Reference(Claim) Id of resource triggering adjudication
ele-1: All FHIR elements must have a @value or children
... outcome SΣ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... disposition S 0..1 string Disposition Message
ele-1: All FHIR elements must have a @value or children
... item S 0..* BackboneElement Adjudication for claim line items
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... itemSequence 1..1 positiveInt Claim item instance identifier
ele-1: All FHIR elements must have a @value or children
.... adjudication 1..* BackboneElement Adjudication details
ele-1: All FHIR elements must have a @value or children
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
..... category 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
ele-1: All FHIR elements must have a @value or children
... total SΣ 0..* BackboneElement Adjudication totals
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... category Σ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.


ele-1: All FHIR elements must have a @value or children
.... amount Σ 1..1 Money Financial total for the category
ele-1: All FHIR elements must have a @value or children
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Code (example): Specify type of document attached with as form.


ele-1: All FHIR elements must have a @value or children
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
ele-1: All FHIR elements must have a @value or children
... insurance S 0..* BackboneElement Patient insurance information
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... sequence 1..1 positiveInt Insurance instance identifier
ele-1: All FHIR elements must have a @value or children
.... focal 1..1 boolean Coverage to be used for adjudication
ele-1: All FHIR elements must have a @value or children
.... coverage S 1..1 Reference(Coverage) Insurance information
ele-1: All FHIR elements must have a @value or children
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
ele-1: All FHIR elements must have a @value or children
... error S 0..* BackboneElement Processing errors
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse ClaimResponse
... type 1..1 CodeableConcept More granular claim type
Binding: Claim Type (extensible)
... patient 1..1 Reference(Patient) The recipient of the products and services
... insurer S 1..1 Reference(Organization) Party responsible for reimbursement
... request S 0..1 Reference(Claim) Id of resource triggering adjudication
... outcome S 1..1 code queued | complete | error | partial
... disposition S 0..1 string Disposition Message
... item S 0..* BackboneElement Adjudication for claim line items
.... adjudication
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
... addItem
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
..... coding
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: Program Code (example)
..... coding
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
...... display 1..1 string Representation defined by the system
.... detail
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
...... coding
....... system 1..1 uri Identity of the terminology system
....... code 1..1 code Symbol in syntax defined by the system
....... display 1..1 string Representation defined by the system
..... subDetail
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
....... coding
........ system 1..1 uri Identity of the terminology system
........ code 1..1 code Symbol in syntax defined by the system
........ display 1..1 string Representation defined by the system
... total S 0..* BackboneElement Adjudication totals
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Code (example): Specify type of document attached with as form.

... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... coverage S 1..1 Reference(Coverage) Insurance information
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error S 0..* BackboneElement Processing errors

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.addItem.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.programCodeexampleProgramCode (a valid code from Program Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code
from this IG
ClaimResponse.addItem.detail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
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 ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.

... type Σ 1..1 CodeableConcept More granular claim type
Binding: Claim Type (extensible)
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.

... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.

... patient Σ 1..1 Reference(Patient) The recipient of the products and services
... created Σ 1..1 dateTime Response creation date
... insurer SΣ 1..1 Reference(Organization) Party responsible for reimbursement
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request SΣ 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 S 0..1 string Disposition Message
... preAuthRef 0..1 string Preauthorization reference
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... payeeType 0..1 CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.

... item S 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 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.

..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (example)
..... 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 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: ProductorService (example)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 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 1..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: Program Code (example)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 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 1..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
.... 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 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: ProductorService (example)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding Σ 0..* Coding Code defined by a terminology system
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... system Σ 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 1..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.


..... 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: ProductorService (example)
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... coding Σ 0..* Coding Code defined by a terminology system
........ id 0..1 string Unique id for inter-element referencing
........ extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
........ system Σ 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 1..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.


...... 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 SΣ 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 Code (example): Specify type of document attached with as form.

... form 0..1 Attachment Printed reference or actual form
... processNote 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 0..1 positiveInt Note instance identifier
.... type 0..1 code display | print | printoper
Binding: NoteType (required): The presentation types of notes.

.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... communicationRequest 0..* Reference(CommunicationRequest) Request for additional information
... insurance S 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 S 1..1 Reference(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error S 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..1 positiveInt Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (example): The adjudication error codes.


doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
ClaimResponse.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
from the FHIR Standard
ClaimResponse.typeextensibleClaimType
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-claim-type
from this IG
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredUse
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReason (a valid code from Adjudication Reason)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-adjudication-reason
from this IG
ClaimResponse.addItem.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleProgramCode (a valid code from Program Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-program-code
from this IG
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleProductorService
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-productorservice
from this IG
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleFormCode (a valid code from Form Code)
https://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-form-code
from this IG
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
from the FHIR Standard
ClaimResponse.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
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()

 

Other representations of profile: CSV, Excel, Schematron