Health New Zealand Te Whatu Ora Shared Care FHIR API
0.4.4 - release

Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.4) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: SharedCareClaimResponse - Detailed Descriptions

Active as of 2025-12-11

Definitions for the SharedCareClaimResponse resource profile.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
Definition | This resource provides the adjudication details from the processing of a Claim resource.
Short | Response to a claim predetermination or preauthorization
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Remittance Advice
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty()) 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 (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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. ClaimResponse.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ClaimResponse.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
6. ClaimResponse.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. ClaimResponse.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. ClaimResponse.identifier
Definition | A unique identifier assigned to this claim response.
Short | Business identifier(s) for the claim responseBusiness Identifier for a claim response
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 10..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claim responses to be distinguished and referenced.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ClaimResponse.identifier.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 10..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ClaimResponse.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | The value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 10..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. ClaimResponse.status
Definition | The status of the resource instance.
Short | Status of the Claim Response: active, cancelled, draft, entered-in-erroractive | cancelled | draft | entered-in-error
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.type
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from NZ Claim Types http://hl7.org/fhir/ValueSet/claim-type (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ClaimResponse.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see NZ Claim Subtypes http://hl7.org/fhir/ValueSet/claim-subtype (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ClaimResponse.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Claim, preauthorization, predetermination.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ClaimResponse.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(Patient)
Is Modifier | false
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ClaimResponse.created
Definition | The date this resource was created.
Short | Date & time of claim determinationResponse creation date
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ClaimResponse.insurer
Definition | The party responsible for authorization, adjudication and reimbursement.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ClaimResponse.requestor
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Short | Party responsible for the ClaimParty responsible for the claim
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Control | 0..1
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ClaimResponse.request
Definition | Original request resource reference.
Short | Reference to the Claim that was determinedId of resource triggering adjudication
Control | 10..1
Type | Reference(NZ SharedCare Claim, Claim)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. ClaimResponse.outcome
Definition | The outcome of the claim, predetermination, or preauthorization processing.
Short | queued | complete | error | partial
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ClaimResponse.item
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Short | Claim response itemsAdjudication for claim line items
Control | 10..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for items provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ClaimResponse.item.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 10..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
42. ClaimResponse.item.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
44. ClaimResponse.item.extension:productOrService
Slice Name | productOrService
Definition | Validation and correction of purchase unit codes for shared care services
Short | Shared Care Product Or Service
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Product Or Service) (Extension Type: CodeableConcept)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
46. ClaimResponse.item.extension:reviewOutcome
Slice Name | reviewOutcome
Definition | Adjudication result for shared care claim items
Short | Shared Care Review Outcome
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
48. ClaimResponse.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
50. ClaimResponse.item.itemSequence
Definition | A number to uniquely reference the claim item entries.
Short | Value of the corresponding Claim.item.sequenceClaim item instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. ClaimResponse.item.adjudication
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Short | Adjudication (reason, amount, quantity) for each Adjudication Value CodeAdjudication details
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. ClaimResponse.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
56. ClaimResponse.item.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
Short | Codified representation of adjudication outcomeType of adjudication information
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see Adjudication Value Codes http://hl7.org/fhir/ValueSet/adjudication (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. ClaimResponse.item.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Codified reason(s) for the adjudicationExplanation of adjudication outcome
Comments | For example may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see Adjudication Reason Codes http://hl7.org/fhir/ValueSet/adjudication-reason (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. ClaimResponse.item.adjudication.amount
Definition | Monetary amount associated with the category.
Short | Monetary value of the adjudicationMonetary amount
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 10..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. ClaimResponse.item.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monetary value of the adjudication
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. ClaimResponse.item.detail
Definition | A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Any sub-determinations of this itemSequenceAdjudication for claim details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for details provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
66. ClaimResponse.item.detail.extension
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | ExtensionAdditional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
Slicing | This element introduces a set of slices on `ClaimResponse.item.detail.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
68. ClaimResponse.item.detail.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
70. ClaimResponse.item.detail.extension:reviewOutcome
Slice Name | reviewOutcome
Definition | Adjudication result for shared care claim items
Short | Shared Care Review Outcome
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
72. ClaimResponse.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
74. ClaimResponse.item.detail.detailSequence
Definition | A number to uniquely reference the claim detail entry.
Short | Value of the corresponding Claim.item.detail.sequenceClaim detail instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. ClaimResponse.item.detail.adjudication
Definition | The adjudication results.
Short | Detail level adjudication details
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. ClaimResponse.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Any line items added by Health NZ to the claim determination that were not in the original claimInsurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. ClaimResponse.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. ClaimResponse.addItem.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls (example to `http://hl7.org/fhir/ValueSet/service-uscls` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. ClaimResponse.addItem.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. ClaimResponse.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Claim-level adjudicationHeader-level adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. ClaimResponse.total
Definition | Categorized monetary totals for the adjudication.
Short | Financial total of the claim for each Adjudication Value CodeAdjudication totals
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | To provide the requestor with financial totals by category for the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. ClaimResponse.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. ClaimResponse.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Short | Type of adjudication information
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | For example codes, see AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication (example to `http://hl7.org/fhir/ValueSet/adjudication` ) The adjudication codes.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Needed to convey the type of total provided.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. ClaimResponse.total.amount
Definition | Monetary total amount associated with the category.
Short | Financial total for the category
Control | 1..1
Type | Money
Is Modifier | false
Summary | true
Requirements | Needed to convey the total monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. ClaimResponse.payment
Definition | Payment details for the adjudication of the claim.
Short | Summary of the payment being madePayment Details
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. ClaimResponse.payment.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
100. ClaimResponse.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Short | Payment Type Code = complete or partialPartial or complete payment
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from For example codes, see Payment Type Codes http://hl7.org/fhir/ValueSet/ex-paymenttype (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. ClaimResponse.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Short | Expected date of payment (if known)
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To advise the payee when payment can be expected.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. ClaimResponse.payment.amount
Definition | Benefits payable less any payment adjustment.
Short | Payment amountPayable amount after adjustment
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Needed to provide the actual payment amount.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. ClaimResponse.error
Definition | Errors encountered during the processing of the adjudication.
Short | Collection of errors produced during claim determinationProcessing errors
Comments | If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Need to communicate processing issues to the requestor.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. ClaimResponse.error.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
110. ClaimResponse.error.itemSequence
Definition | The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Refers to itemSequence to which the error relatesItem sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. ClaimResponse.error.detailSequence
Definition | The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Refers to detailSequence to which the error relatesDetail sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. ClaimResponse.error.code
Definition | An error code, from a specified code system, which details why the claim could not be adjudicated.
Short | Error codeError code detailing processing issues
Control | 1..1
Binding | For example codes, see Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error (example to `http://hl7.org/fhir/ValueSet/adjudication-error` ) The adjudication error codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to convey processing errors.
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
2. ClaimResponse.meta
4. ClaimResponse.meta.source
Definition | Captures the source of the record. This must contain the HPIFacilityID e.g. https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A
Short | HPI Facility ID from where the record is sourced
Control | 1..?
Invariants | hpi-location-url-format: Reference must be an HPI facility URL with format https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A (`matches('^https://standards.digital.health.nz/ns/hpi-facility-id/F[A-Za-z0-9]{2}[0-9]{3}-[A-Za-z0-9]$')`)
6. ClaimResponse.meta.tag
Control | 1..?
Slicing | This element introduces a set of slices on `ClaimResponse.meta.tag`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ system
8. ClaimResponse.meta.tag:correlationId
Slice Name | correlationId
Control | 1..1
10. ClaimResponse.meta.tag:correlationId.system
Control | 1..?
Fixed Value | `https://hub.services.digital.health.nz/ns/correlation-id`
12. ClaimResponse.meta.tag:correlationId.code
Control | 1..?
14. ClaimResponse.extension
Slicing | This element introduces a set of slices on `ClaimResponse.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
16. ClaimResponse.extension:traceNumber
Slice Name | traceNumber
Control | 0..*
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
18. ClaimResponse.identifier
Short | Business identifier(s) for the claim response
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..?
20. ClaimResponse.identifier.system
Control | 1..?
22. ClaimResponse.identifier.value
Control | 1..?
24. ClaimResponse.status
Short | Status of the Claim Response: active, cancelled, draft, entered-in-error
26. ClaimResponse.type
Binding | Unless not suitable, these codes SHALL be taken from NZ Claim Types (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types` )
28. ClaimResponse.subType
Binding | Unless not suitable, these codes SHALL be taken from NZ Claim Subtypes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes` )
30. ClaimResponse.created
Short | Date & time of claim determination
32. ClaimResponse.requestor
Short | Party responsible for the Claim
34. ClaimResponse.request
Short | Reference to the Claim that was determined
Control | 1..?
Type | Reference(NZ SharedCare Claim)
36. ClaimResponse.item
Short | Claim response items
Control | 1..?
38. ClaimResponse.item.extension
Control | 1..?
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
40. ClaimResponse.item.extension:traceNumber
Slice Name | traceNumber
Control | 0..*
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
42. ClaimResponse.item.extension:productOrService
Slice Name | productOrService
Control | 1..1
Type | Extension(Shared Care Product Or Service) (Extension Type: CodeableConcept)
44. ClaimResponse.item.extension:reviewOutcome
Slice Name | reviewOutcome
Control | 0..1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
46. ClaimResponse.item.itemSequence
Short | Value of the corresponding Claim.item.sequence
48. ClaimResponse.item.adjudication
Short | Adjudication (reason, amount, quantity) for each Adjudication Value Code
50. ClaimResponse.item.adjudication.category
Short | Codified representation of adjudication outcome
Binding | Unless not suitable, these codes SHALL be taken from Adjudication Value Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes` )
52. ClaimResponse.item.adjudication.reason
Short | Codified reason(s) for the adjudication
Binding | Unless not suitable, these codes SHALL be taken from Adjudication Reason Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes` )
54. ClaimResponse.item.adjudication.amount
Short | Monetary value of the adjudication
Control | 1..?
56. ClaimResponse.item.adjudication.value
Short | Non-monetary value of the adjudication
58. ClaimResponse.item.detail
Short | Any sub-determinations of this itemSequence
60. ClaimResponse.item.detail.extension
Slicing | This element introduces a set of slices on `ClaimResponse.item.detail.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
62. ClaimResponse.item.detail.extension:traceNumber
Slice Name | traceNumber
Control | 0..*
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
64. ClaimResponse.item.detail.extension:reviewOutcome
Slice Name | reviewOutcome
Control | 0..1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
66. ClaimResponse.item.detail.detailSequence
Short | Value of the corresponding Claim.item.detail.sequence
68. ClaimResponse.addItem
Short | Any line items added by Health NZ to the claim determination that were not in the original claim
70. ClaimResponse.adjudication
Short | Claim-level adjudication
72. ClaimResponse.total
Short | Financial total of the claim for each Adjudication Value Code
74. ClaimResponse.payment
Short | Summary of the payment being made
76. ClaimResponse.payment.type
Short | Payment Type Code = complete or partial
Binding | Unless not suitable, these codes SHALL be taken from Payment Type Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes` )
78. ClaimResponse.payment.date
Short | Expected date of payment (if known)
80. ClaimResponse.payment.amount
Short | Payment amount
82. ClaimResponse.error
Short | Collection of errors produced during claim determination
84. ClaimResponse.error.itemSequence
Short | Refers to itemSequence to which the error relates
86. ClaimResponse.error.detailSequence
Short | Refers to detailSequence to which the error relates
88. ClaimResponse.error.code
Short | Error code

Guidance on how to interpret the contents of this table can be foundhere

0. ClaimResponse
Definition | This resource provides the adjudication details from the processing of a Claim resource.
Short | Response to a claim predetermination or preauthorization
Control | 0..*
Is Modifier | false
Summary | false
Alternate Names | Remittance Advice
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (`contained.contained.empty()`) 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 (`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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (`contained.meta.security.empty()`) dom-6: A resource should have narrative for robust management (`text.`div`.exists()`)
2. ClaimResponse.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Short | Logical id of this artifact
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
Control | 0..1
Type | id
Is Modifier | false
Summary | true
4. ClaimResponse.meta
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
Short | Metadata about the resource
Control | 0..1
Type | Meta
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
6. ClaimResponse.meta.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
8. ClaimResponse.meta.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.meta.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
10. ClaimResponse.meta.versionId
Definition | The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Short | Version specific identifier
Comments | The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
Control | 0..1
Type | id
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
12. ClaimResponse.meta.lastUpdated
Definition | When the resource last changed - e.g. when the version changed.
Short | When the resource version last changed
Comments | This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
Control | 0..1
Type | instant
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
14. ClaimResponse.meta.source
Definition | Captures the source of the record. This must contain the HPIFacilityID e.g. https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A
Short | HPI Facility ID from where the record is sourced
Comments | In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) hpi-location-url-format: Reference must be an HPI facility URL with format https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A (`matches('^https://standards.digital.health.nz/ns/hpi-facility-id/F[A-Za-z0-9]{2}[0-9]{3}-[A-Za-z0-9]$')`)
16. ClaimResponse.meta.profile
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.
Short | Profiles this resource claims to conform to
Comments | It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Control | 0..*
Type | canonical(StructureDefinition)
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
18. ClaimResponse.meta.security
Definition | Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
Short | Security Labels applied to this resource
Comments | The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Control | 0..*
Binding | Unless not suitable, these codes SHALL be taken from All Security Labels (extensible to `http://hl7.org/fhir/ValueSet/security-labels` ) Security Labels from the Healthcare Privacy and Security Classification System.
Type | Coding
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
20. ClaimResponse.meta.tag
Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Short | Tags applied to this resource
Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Control | 1..*
Binding | For example codes, see CommonTags (example to `http://hl7.org/fhir/ValueSet/common-tags` ) Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
Type | Coding
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
Slicing | This element introduces a set of slices on `ClaimResponse.meta.tag`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ system
22. ClaimResponse.meta.tag:correlationId
Slice Name | correlationId
Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
Short | Tags applied to this resource
Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Control | 1..1
Binding | For example codes, see CommonTags (example to `http://hl7.org/fhir/ValueSet/common-tags` ) Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
Type | Coding
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
24. ClaimResponse.meta.tag:correlationId.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
26. ClaimResponse.meta.tag:correlationId.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.meta.tag.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
28. ClaimResponse.meta.tag:correlationId.system
Definition | The identification of the code system that defines the meaning of the symbol in the code.
Short | Identity of the terminology system
Comments | The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to be unambiguous about the source of the definition of the symbol.
Fixed Value | `https://hub.services.digital.health.nz/ns/correlation-id`
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
30. ClaimResponse.meta.tag:correlationId.version
Definition | The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Short | Version of the system - if relevant
Comments | Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
Note | This is a business version Id, not a resource version Id (see discussion)
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
32. ClaimResponse.meta.tag:correlationId.code
Definition | A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Short | Symbol in syntax defined by the system
Control | 1..1
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to refer to a particular code in the system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
34. ClaimResponse.meta.tag:correlationId.display
Definition | A representation of the meaning of the code in the system, following the rules of the system.
Short | Representation defined by the system
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
36. ClaimResponse.meta.tag:correlationId.userSelected
Definition | Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Short | If this coding was chosen directly by the user
Comments | Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
Control | 0..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
38. ClaimResponse.implicitRules
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Short | A set of rules under which this content was created
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
Control | 0..1
Type | uri
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
40. ClaimResponse.language
Definition | The base language in which the resource is written.
Short | Language of the resource content
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
42. ClaimResponse.text
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Short | Text summary of the resource, for human interpretation
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
Control | 0..1
Type | Narrative
Is Modifier | false
Summary | false
Alternate Names | narrative, html, xhtml, display
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
44. ClaimResponse.contained
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
Short | Contained, inline Resources
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Control | 0..*
Type | Resource
Is Modifier | false
Summary | false
Alternate Names | inline resources, anonymous resources, contained resources
46. ClaimResponse.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
48. ClaimResponse.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
50. ClaimResponse.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summary | false
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
52. ClaimResponse.identifier
Definition | A unique identifier assigned to this claim response.
Short | Business identifier(s) for the claim response
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 1..*
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Allows claim responses to be distinguished and referenced.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
54. ClaimResponse.identifier.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
56. ClaimResponse.identifier.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.identifier.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
58. ClaimResponse.identifier.use
Definition | The purpose of this identifier.
Short | usual | official | temp | secondary | old (If known)
Comments | Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Control | 0..1
Binding | The codes SHALL be taken from IdentifierUse (required to `http://hl7.org/fhir/ValueSet/identifier-use|4.0.1` ) Identifies the purpose for this identifier, if known .
Type | code
Is Modifier | true because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
60. ClaimResponse.identifier.type
Definition | A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
Short | Description of identifier
Comments | This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from Identifier Type Codes (extensible to `http://hl7.org/fhir/ValueSet/identifier-type` ) A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Allows users to make use of identifiers when the identifier system is not known.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
62. ClaimResponse.identifier.system
Definition | Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Short | The namespace for the identifier value
Comments | Identifier.system is always case sensitive.
Control | 1..1
Type | uri
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.
Example | General: http://www.acme.com/identifiers/patient
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
64. ClaimResponse.identifier.value
Definition | The portion of the identifier typically relevant to the user and which is unique within the context of the system.
Short | The value that is unique
Comments | If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Example | General: 123456
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
66. ClaimResponse.identifier.period
Definition | Time period during which identifier is/was valid for use.
Short | Time period when id is/was valid for use
Control | 0..1
Type | Period
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
68. ClaimResponse.identifier.assigner
Definition | Organization that issued/manages the identifier.
Short | Organization that issued id (may be just text)
Comments | The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
Control | 0..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
70. ClaimResponse.status
Definition | The status of the resource instance.
Short | Status of the Claim Response: active, cancelled, draft, entered-in-error
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Control | 1..1
Binding | The codes SHALL be taken from FinancialResourceStatusCodes (required to `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` ) A code specifying the state of the resource instance.
Type | code
Is Modifier | true because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
72. ClaimResponse.type
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from NZ Claim Types (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types` )
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
74. ClaimResponse.subType
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
Short | More granular claim type
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from NZ Claim Subtypes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
76. ClaimResponse.use
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.
Short | claim | preauthorization | predetermination
Control | 1..1
Binding | The codes SHALL be taken from Use (required to `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` ) Claim, preauthorization, predetermination.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | This element is required to understand the nature of the request for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
78. ClaimResponse.patient
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
Short | The recipient of the products and services
Control | 1..1
Type | Reference(Patient)
Is Modifier | false
Summary | true
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
80. ClaimResponse.created
Definition | The date this resource was created.
Short | Date & time of claim determination
Control | 1..1
Type | dateTime
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Need to record a timestamp for use by both the recipient and the issuer.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
82. ClaimResponse.insurer
Definition | The party responsible for authorization, adjudication and reimbursement.
Short | Party responsible for reimbursement
Control | 1..1
Type | Reference(Organization)
Is Modifier | false
Summary | true
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
84. ClaimResponse.requestor
Definition | The provider which is responsible for the claim, predetermination or preauthorization.
Short | Party responsible for the Claim
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.
Control | 0..1
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
86. ClaimResponse.request
Definition | Original request resource reference.
Short | Reference to the Claim that was determined
Control | 1..1
Type | Reference(NZ SharedCare Claim)
Is Modifier | false
Summary | true
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
88. ClaimResponse.outcome
Definition | The outcome of the claim, predetermination, or preauthorization processing.
Short | queued | complete | error | partial
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).
Control | 1..1
Binding | The codes SHALL be taken from ClaimProcessingCodes (required to `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` ) The result of the claim processing.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | To advise the requestor of an overall processing outcome.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
90. ClaimResponse.disposition
Definition | A human readable description of the status of the adjudication.
Short | Disposition Message
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provided for user display.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
92. ClaimResponse.preAuthRef
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication.
Short | Preauthorization reference
Comments | This value is only present on preauthorization adjudications.
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | On subsequent claims, the insurer may require the provider to quote this value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
94. ClaimResponse.preAuthPeriod
Definition | The time frame during which this authorization is effective.
Short | Preauthorization reference effective period
Control | 0..1
Type | Period
Is Modifier | false
Summary | false
Requirements | To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
96. ClaimResponse.payeeType
Definition | Type of Party to be reimbursed: subscriber, provider, other.
Short | Party to be paid any benefits payable
Control | 0..1
Binding | For example codes, see Claim Payee Type Codes (example to `http://hl7.org/fhir/ValueSet/payeetype` ) A code for the party to be reimbursed.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
98. ClaimResponse.item
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
Short | Claim response items
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for items provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
100. ClaimResponse.item.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
102. ClaimResponse.item.extension
Definition | An Extension
Short | Extension
Control | 1..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.item.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
104. ClaimResponse.item.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
106. ClaimResponse.item.extension:productOrService
Slice Name | productOrService
Definition | Validation and correction of purchase unit codes for shared care services
Short | Shared Care Product Or Service
Control | 1..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Product Or Service) (Extension Type: CodeableConcept)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
108. ClaimResponse.item.extension:reviewOutcome
Slice Name | reviewOutcome
Definition | Adjudication result for shared care claim items
Short | Shared Care Review Outcome
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
110. ClaimResponse.item.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
112. ClaimResponse.item.itemSequence
Definition | A number to uniquely reference the claim item entries.
Short | Value of the corresponding Claim.item.sequence
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
114. ClaimResponse.item.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
116. ClaimResponse.item.adjudication
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
Short | Adjudication (reason, amount, quantity) for each Adjudication Value Code
Control | 1..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
118. ClaimResponse.item.adjudication.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
120. ClaimResponse.item.adjudication.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
122. ClaimResponse.item.adjudication.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
124. ClaimResponse.item.adjudication.category
Definition | A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
Short | Codified representation of adjudication outcome
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from Adjudication Value Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to enable understanding of the context of the other information in the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
126. ClaimResponse.item.adjudication.reason
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount.
Short | Codified reason(s) for the adjudication
Comments | For example may indicate that the funds for this benefit type have been exhausted.
Control | 0..1
Binding | Unless not suitable, these codes SHALL be taken from Adjudication Reason Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support understanding of variance from adjudication expectations.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
128. ClaimResponse.item.adjudication.amount
Definition | Monetary amount associated with the category.
Short | Monetary value of the adjudication
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable.
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Most adjuciation categories convey a monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
130. ClaimResponse.item.adjudication.value
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above.
Short | Non-monetary value of the adjudication
Comments | For example: eligible percentage or co-payment percentage.
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Some adjudication categories convey a percentage or a fixed value.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
132. ClaimResponse.item.detail
Definition | A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
Short | Any sub-determinations of this itemSequence
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for details provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
134. ClaimResponse.item.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
136. ClaimResponse.item.detail.extension
Definition | An Extension
Short | Extension
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
Slicing | This element introduces a set of slices on `ClaimResponse.item.detail.extension`. The slices areUnordered and Open, and can be differentiated using the following discriminators: value @ url
138. ClaimResponse.item.detail.extension:traceNumber
Slice Name | traceNumber
Definition | Internal primary key ID for shared care claim tracking
Short | Shared Care Claim Trace Number
Control | 0..* This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Claim Trace Number) (Extension Type: Identifier)
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
140. ClaimResponse.item.detail.extension:reviewOutcome
Slice Name | reviewOutcome
Definition | Adjudication result for shared care claim items
Short | Shared Care Review Outcome
Control | 0..1 This element is affected by the following invariants: ele-1
Type | Extension(Shared Care Review Outcome) (Complex Extension)
Is Modifier | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
142. ClaimResponse.item.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
144. ClaimResponse.item.detail.detailSequence
Definition | A number to uniquely reference the claim detail entry.
Short | Value of the corresponding Claim.item.detail.sequence
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
146. ClaimResponse.item.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
148. ClaimResponse.item.detail.adjudication
Definition | The adjudication results.
Short | Detail level adjudication details
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
150. ClaimResponse.item.detail.subDetail
Definition | A sub-detail adjudication of a simple product or service.
Short | Adjudication for claim sub-details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | The adjudication for sub-details provided on the claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
152. ClaimResponse.item.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
154. ClaimResponse.item.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
156. ClaimResponse.item.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
158. ClaimResponse.item.detail.subDetail.subDetailSequence
Definition | A number to uniquely reference the claim sub-detail entry.
Short | Claim sub-detail instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
160. ClaimResponse.item.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
162. ClaimResponse.item.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Subdetail level adjudication details
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
164. ClaimResponse.addItem
Definition | The first-tier service adjudications for payor added product or service lines.
Short | Any line items added by Health NZ to the claim determination that were not in the original claim
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
166. ClaimResponse.addItem.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
168. ClaimResponse.addItem.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
170. ClaimResponse.addItem.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
172. ClaimResponse.addItem.itemSequence
Definition | Claim items which this service line is intended to replace.
Short | Item sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
174. ClaimResponse.addItem.detailSequence
Definition | The sequence number of the details within the claim item which this line is intended to replace.
Short | Detail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
176. ClaimResponse.addItem.subdetailSequence
Definition | The sequence number of the sub-details within the details within the claim item which this line is intended to replace.
Short | Subdetail sequence number
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
178. ClaimResponse.addItem.provider
Definition | The providers who are authorized for the services rendered to the patient.
Short | Authorized providers
Control | 0..*
Type | Reference(Practitioner, PractitionerRole, Organization)
Is Modifier | false
Summary | false
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
180. ClaimResponse.addItem.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
182. ClaimResponse.addItem.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
184. ClaimResponse.addItem.programCode
Definition | Identifies the program under which this may be recovered.
Short | Program the product or service is provided under
Comments | For example: Neonatal program, child dental program or drug users recovery program.
Control | 0..*
Binding | For example codes, see ExampleProgramReasonCodes (example to `http://hl7.org/fhir/ValueSet/ex-program-code` ) Program specific reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
186. ClaimResponse.addItem.serviced[x]
Definition | The date or dates when the service or product was supplied, performed or completed.
Short | Date or dates of service or product delivery
Control | 0..1
Type | Choice of: date, Period
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
188. ClaimResponse.addItem.location[x]
Definition | Where the product or service was provided.
Short | Place of service or where product was supplied
Control | 0..1
Binding | For example codes, see ExampleServicePlaceCodes (example to `http://hl7.org/fhir/ValueSet/service-place` ) Place of service: pharmacy, school, prison, etc.
Type | Choice of: CodeableConcept, Address, Reference(Location)
[x] Note | SeeChoice of Data Typesfor further information about how to use [x]
Is Modifier | false
Summary | false
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
190. ClaimResponse.addItem.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
192. ClaimResponse.addItem.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
194. ClaimResponse.addItem.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
196. ClaimResponse.addItem.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
198. ClaimResponse.addItem.bodySite
Definition | Physical service site on the patient (limb, tooth, etc.).
Short | Anatomical location
Comments | For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Control | 0..1
Binding | For example codes, see OralSiteCodes (example to `http://hl7.org/fhir/ValueSet/tooth` ) The code for the teeth, quadrant, sextant and arch.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
200. ClaimResponse.addItem.subSite
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s).
Short | Anatomical sub-location
Control | 0..*
Binding | For example codes, see SurfaceCodes (example to `http://hl7.org/fhir/ValueSet/surface` ) The code for the tooth surface and surface combinations.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Allows insurer to validate specific procedures.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
202. ClaimResponse.addItem.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
204. ClaimResponse.addItem.adjudication
Definition | The adjudication results.
Short | Added items adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
206. ClaimResponse.addItem.detail
Definition | The second-tier service adjudications for payor added services.
Short | Insurer added line details
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
208. ClaimResponse.addItem.detail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
210. ClaimResponse.addItem.detail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
212. ClaimResponse.addItem.detail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
214. ClaimResponse.addItem.detail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
216. ClaimResponse.addItem.detail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
218. ClaimResponse.addItem.detail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
220. ClaimResponse.addItem.detail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
222. ClaimResponse.addItem.detail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
224. ClaimResponse.addItem.detail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
226. ClaimResponse.addItem.detail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
228. ClaimResponse.addItem.detail.adjudication
Definition | The adjudication results.
Short | Added items detail adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
230. ClaimResponse.addItem.detail.subDetail
Definition | The third-tier service adjudications for payor added services.
Short | Insurer added line items
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
232. ClaimResponse.addItem.detail.subDetail.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
234. ClaimResponse.addItem.detail.subDetail.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
236. ClaimResponse.addItem.detail.subDetail.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
238. ClaimResponse.addItem.detail.subDetail.productOrService
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.
Short | Billing, service, product, or drug code
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Control | 1..1
Binding | For example codes, see USCLSCodes (example to `http://hl7.org/fhir/ValueSet/service-uscls` ) Allowable service and product codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Necessary to state what was provided or done.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
240. ClaimResponse.addItem.detail.subDetail.modifier
Definition | Item typification or modifiers codes to convey additional context for the product or service.
Short | Service/Product billing modifiers
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
Control | 0..*
Binding | For example codes, see ModifierTypeCodes (example to `http://hl7.org/fhir/ValueSet/claim-modifiers` ) Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
242. ClaimResponse.addItem.detail.subDetail.quantity
Definition | The number of repetitions of a service or product.
Short | Count of products or services
Control | 0..1
Type | Quantity(SimpleQuantity)
Is Modifier | false
Summary | false
Requirements | Required when the product or service code does not convey the quantity provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
244. ClaimResponse.addItem.detail.subDetail.unitPrice
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
Short | Fee, charge or cost per item
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | The amount charged to the patient by the provider for a single unit.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
246. ClaimResponse.addItem.detail.subDetail.factor
Definition | A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
Short | Price scaling factor
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
Control | 0..1
Type | decimal
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
248. ClaimResponse.addItem.detail.subDetail.net
Definition | The quantity times the unit price for an additional service or product or charge.
Short | Total item cost
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
250. ClaimResponse.addItem.detail.subDetail.noteNumber
Definition | The numbers associated with notes below which apply to the adjudication of this item.
Short | Applicable note numbers
Control | 0..*
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
252. ClaimResponse.addItem.detail.subDetail.adjudication
Definition | The adjudication results.
Short | Added items detail adjudication
Control | 1..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
254. ClaimResponse.adjudication
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Short | Claim-level adjudication
Control | 0..*
Type | Seettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifier | false
Summary | false
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
256. ClaimResponse.total
Definition | Categorized monetary totals for the adjudication.
Short | Financial total of the claim for each Adjudication Value Code
Comments | Totals for amounts submitted, co-pays, benefits payable etc.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | true
Requirements | To provide the requestor with financial totals by category for the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
258. ClaimResponse.total.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
260. ClaimResponse.total.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
262. ClaimResponse.total.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
264. ClaimResponse.total.category
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Short | Type of adjudication information
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Control | 1..1
Binding | For example codes, see AdjudicationValueCodes (example to `http://hl7.org/fhir/ValueSet/adjudication` ) The adjudication codes.
Type | CodeableConcept
Is Modifier | false
Summary | true
Requirements | Needed to convey the type of total provided.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
266. ClaimResponse.total.amount
Definition | Monetary total amount associated with the category.
Short | Financial total for the category
Control | 1..1
Type | Money
Is Modifier | false
Summary | true
Requirements | Needed to convey the total monetary amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
268. ClaimResponse.payment
Definition | Payment details for the adjudication of the claim.
Short | Summary of the payment being made
Control | 0..1
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
270. ClaimResponse.payment.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
272. ClaimResponse.payment.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
274. ClaimResponse.payment.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
276. ClaimResponse.payment.type
Definition | Whether this represents partial or complete payment of the benefits payable.
Short | Payment Type Code = complete or partial
Control | 1..1
Binding | Unless not suitable, these codes SHALL be taken from Payment Type Codes (extensible to `https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes` )
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | To advise the requestor when the insurer believes all payments to have been completed.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
278. ClaimResponse.payment.adjustment
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Short | Payment adjustment for non-claim issues
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
Control | 0..1
Type | Money
Is Modifier | false
Summary | false
Requirements | To advise the requestor of adjustments applied to the payment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
280. ClaimResponse.payment.adjustmentReason
Definition | Reason for the payment adjustment.
Short | Explanation for the adjustment
Control | 0..1
Binding | For example codes, see PaymentAdjustmentReasonCodes (example to `http://hl7.org/fhir/ValueSet/payment-adjustment-reason` ) Payment Adjustment reason codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to clarify the monetary adjustment.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
282. ClaimResponse.payment.date
Definition | Estimated date the payment will be issued or the actual issue date of payment.
Short | Expected date of payment (if known)
Control | 0..1
Type | date
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To advise the payee when payment can be expected.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
284. ClaimResponse.payment.amount
Definition | Benefits payable less any payment adjustment.
Short | Payment amount
Control | 1..1
Type | Money
Is Modifier | false
Summary | false
Requirements | Needed to provide the actual payment amount.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
286. ClaimResponse.payment.identifier
Definition | Issuer's unique identifier for the payment instrument.
Short | Business identifier for the payment
Comments | For example: EFT number or check number.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..1
Type | Identifier
Is Modifier | false
Summary | false
Requirements | Enable the receiver to reconcile when payment received.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
288. ClaimResponse.fundsReserve
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Short | Funds reserved status
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Control | 0..1
Binding | For example codes, see Funds Reservation Codes (example to `http://hl7.org/fhir/ValueSet/fundsreserve` ) For whom funds are to be reserved: (Patient, Provider, None).
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
290. ClaimResponse.formCode
Definition | A code for the form to be used for printing the content.
Short | Printed form identifier
Comments | May be needed to identify specific jurisdictional forms.
Control | 0..1
Binding | For example codes, see Form Codes (example to `http://hl7.org/fhir/ValueSet/forms` ) The forms codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Needed to specify the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
292. ClaimResponse.form
Definition | The actual form, by reference or inclusion, for printing the content or an EOB.
Short | Printed reference or actual form
Comments | Needed to permit insurers to include the actual form.
Control | 0..1
Type | Attachment
Is Modifier | false
Summary | false
Requirements | Needed to include the specific form used for producing output for this response.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
294. ClaimResponse.processNote
Definition | A note that describes or explains adjudication results in a human readable form.
Short | Note concerning adjudication
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Provides the insurer specific textual explanations associated with the processing.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
296. ClaimResponse.processNote.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
298. ClaimResponse.processNote.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
300. ClaimResponse.processNote.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
302. ClaimResponse.processNote.number
Definition | A number to uniquely identify a note entry.
Short | Note instance identifier
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Necessary to provide a mechanism to link from adjudications.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
304. ClaimResponse.processNote.type
Definition | The business purpose of the note text.
Short | display | print | printoper
Control | 0..1
Binding | The codes SHALL be taken from NoteType (required to `http://hl7.org/fhir/ValueSet/note-type|4.0.1` ) The presentation types of notes.
Type | code
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To convey the expectation for when the text is used.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
306. ClaimResponse.processNote.text
Definition | The explanation or description associated with the processing.
Short | Note explanatory text
Control | 1..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Required to provide human readable explanation.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
308. ClaimResponse.processNote.language
Definition | A code to define the language used in the text of the note.
Short | Language of the text
Comments | Only required if the language is different from the resource language.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages (preferred to `http://hl7.org/fhir/ValueSet/languages` ) A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Note text may vary from the resource defined language.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
310. ClaimResponse.communicationRequest
Definition | Request for additional supporting or authorizing information.
Short | Request for additional information
Comments | For example: professional reports, documents, images, clinical resources, or accident reports.
Control | 0..*
Type | Reference(CommunicationRequest)
Is Modifier | false
Summary | false
Requirements | Need to communicate insurer request for additional information required to support the adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
312. ClaimResponse.insurance
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim.
Short | Patient insurance information
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | At least one insurer is required for a claim to be a claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
314. ClaimResponse.insurance.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
316. ClaimResponse.insurance.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
318. ClaimResponse.insurance.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
320. ClaimResponse.insurance.sequence
Definition | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
Short | Insurance instance identifier
Control | 1..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To maintain order of the coverages.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
322. ClaimResponse.insurance.focal
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
Short | Coverage to be used for adjudication
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
Control | 1..1
Type | boolean
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | To identify which coverage in the list is being used to adjudicate this claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
324. ClaimResponse.insurance.coverage
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Short | Insurance information
Control | 1..1
Type | Reference(Coverage)
Is Modifier | false
Summary | false
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
326. ClaimResponse.insurance.businessArrangement
Definition | A business agreement number established between the provider and the insurer for special business processing purposes.
Short | Additional provider contract number
Control | 0..1
Type | string
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
328. ClaimResponse.insurance.claimResponse
Definition | The result of the adjudication of the line items for the Coverage specified in this insurance.
Short | Adjudication results
Comments | Must not be specified when 'focal=true' for this insurance.
Control | 0..1
Type | Reference(ClaimResponse)
Is Modifier | false
Summary | false
Requirements | An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
330. ClaimResponse.error
Definition | Errors encountered during the processing of the adjudication.
Short | Collection of errors produced during claim determination
Comments | If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Control | 0..*
Type | BackboneElement
Is Modifier | false
Summary | false
Requirements | Need to communicate processing issues to the requestor.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
332. ClaimResponse.error.id
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Short | Unique id for inter-element referencing
Control | 0..1
Type | string
Is Modifier | false
XML Format | In the XML format, this property is represented as an attribute.
Summary | false
334. ClaimResponse.error.extension
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Short | Additional content defined by implementations
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | false
Summary | false
Alternate Names | extensions, user content
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
336. ClaimResponse.error.modifierExtension
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Short | Extensions that cannot be ignored even if unrecognized
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Control | 0..*
Type | Extension
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summary | true
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.
Alternate Names | extensions, user content, modifiers
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`) ext-1: Must have either extensions or value[x], not both (`extension.exists() != value.exists()`)
338. ClaimResponse.error.itemSequence
Definition | The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Refers to itemSequence to which the error relates
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim items.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
340. ClaimResponse.error.detailSequence
Definition | The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Refers to detailSequence to which the error relates
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim details within the claim item.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
342. ClaimResponse.error.subDetailSequence
Definition | The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
Short | Subdetail sequence number
Control | 0..1
Type | positiveInt
Is Modifier | false
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
Requirements | Provides references to the claim sub-details within the claim detail.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)
344. ClaimResponse.error.code
Definition | An error code, from a specified code system, which details why the claim could not be adjudicated.
Short | Error code
Control | 1..1
Binding | For example codes, see Adjudication Error Codes (example to `http://hl7.org/fhir/ValueSet/adjudication-error` ) The adjudication error codes.
Type | CodeableConcept
Is Modifier | false
Summary | false
Requirements | Required to convey processing errors.
Invariants | ele-1: All FHIR elements must have a @value or children (`hasValue() or (children().count() > id.count())`)