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: New Zealand Pharmacy Claim Response

Official URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/NzPharmacyClaimResponse | Version: 0.4.4
Active as of 2025-12-11 | Computable Name: NzPharmacyClaimResponse

FHIR profile for New Zealand pharmacy claim responses

Usages:

- Examples for this Profile: ClaimResponse/NzPharmacyClaimResponseExample

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | DateValidated
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
request | Σ | 1..1 | Reference(Claim) | Reference to the original Claim
outcome | Σ | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
item |  | 1..* | BackboneElement | Adjudication for claim line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
payment |  | 0..1 | BackboneElement | Payment details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
ClaimResponse.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
ClaimResponse.use | required | Use `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype` From the FHIR Standard

#### Constraints

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

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
created |  | 1..1 | dateTime | DateValidated
request |  | 1..1 | Reference(Claim) | Reference to the original Claim
outcome |  | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
item |  | 1..* | BackboneElement | Adjudication for claim line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
payment |  | 0..1 | BackboneElement | Payment details
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
error |  |  |  |
itemSequence |  | 1..1 | positiveInt | Item sequence number
detailSequence |  | 1..1 | positiveInt | Detail sequence number
code |  | 1..1 | CodeableConcept | Error code Binding: Adjudication Error Codes (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.error.code | required | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error` From the FHIR Standard

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | DateValidated
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 1..1 | Reference(Claim) | Reference to the original Claim
outcome | Σ | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 1..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Item sequence number
detailSequence |  | 1..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code Binding: Adjudication Error Codes (required)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
ClaimResponse.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
ClaimResponse.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype` From the FHIR Standard
ClaimResponse.use | required | Use `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.payeeType | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes `http://hl7.org/fhir/ValueSet/adjudication-reason` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.item.detail.adjudication.reason | example | AdjudicationReasonCodes `http://hl7.org/fhir/ValueSet/adjudication-reason` From the FHIR Standard
ClaimResponse.addItem.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes `http://hl7.org/fhir/ValueSet/service-place` From the FHIR Standard
ClaimResponse.addItem.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth` From the FHIR Standard
ClaimResponse.addItem.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface` From the FHIR Standard
ClaimResponse.addItem.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.total.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype` From the FHIR Standard
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes `http://hl7.org/fhir/ValueSet/payment-adjustment-reason` From the FHIR Standard
ClaimResponse.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve` From the FHIR Standard
ClaimResponse.formCode | example | Form Codes `http://hl7.org/fhir/ValueSet/forms` From the FHIR Standard
ClaimResponse.processNote.type | required | NoteType `http://hl7.org/fhir/ValueSet/note-type|4.0.1` From the FHIR Standard
ClaimResponse.processNote.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.error.code | required | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error` From the FHIR Standard

#### Constraints

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

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements(2 nested mandatory elements)

Extensions

This structure refers to these extensions:

- https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
- https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | DateValidated
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
request | Σ | 1..1 | Reference(Claim) | Reference to the original Claim
outcome | Σ | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
item |  | 1..* | BackboneElement | Adjudication for claim line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
payment |  | 0..1 | BackboneElement | Payment details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
ClaimResponse.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
ClaimResponse.use | required | Use `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype` From the FHIR Standard

#### Constraints

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

Differential View

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
created |  | 1..1 | dateTime | DateValidated
request |  | 1..1 | Reference(Claim) | Reference to the original Claim
outcome |  | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
item |  | 1..* | BackboneElement | Adjudication for claim line items
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
payment |  | 0..1 | BackboneElement | Payment details
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
error |  |  |  |
itemSequence |  | 1..1 | positiveInt | Item sequence number
detailSequence |  | 1..1 | positiveInt | Detail sequence number
code |  | 1..1 | CodeableConcept | Error code Binding: Adjudication Error Codes (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.error.code | required | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error` From the FHIR Standard

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 0..1 | Meta | Metadata about the resource
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:traceNumber |  | 0..* | Identifier | Number for tracking URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 1..1 | Identifier | FileId - Should match the Claim id
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient | Σ | 1..1 | Reference(Patient) | The recipient of the products and services
created | Σ | 1..1 | dateTime | DateValidated
insurer | Σ | 1..1 | Reference(Organization) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 1..1 | Reference(Claim) | Reference to the original Claim
outcome | Σ | 1..1 | code | Claim processing outcome Binding: ClaimProcessingCodes (required)
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 1..* | BackboneElement | Adjudication for claim line items
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:productOrService |  | 1..1 | CodeableConcept | Purchase unit code URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | To match Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
detail |  | 1..* | BackboneElement | Adjudication for claim detail items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
detailSequence |  | 1..1 | positiveInt | To match Claim.item.detail.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details breakdown
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | Type of adjudication information Binding: Pharmacy Adjudication Category (extensible)
reason |  | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | Σ | 0..* | BackboneElement | Adjudication totals
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Payment date
amount |  | 1..1 | Money | Payment amount
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | Processing errors
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Item sequence number
detailSequence |  | 1..1 | positiveInt | Detail sequence number
subDetailSequence |  | 0..1 | positiveInt | Subdetail sequence number
code |  | 1..1 | CodeableConcept | Error code Binding: Adjudication Error Codes (required)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
ClaimResponse.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.status | required | FinancialResourceStatusCodes `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | ClaimTypeCodes `http://hl7.org/fhir/ValueSet/claim-type` From the FHIR Standard
ClaimResponse.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype` From the FHIR Standard
ClaimResponse.use | required | Use `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome` From the FHIR Standard
ClaimResponse.payeeType | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodes `http://hl7.org/fhir/ValueSet/adjudication-reason` From the FHIR Standard
ClaimResponse.item.detail.adjudication.category | extensible | PharmacyAdjudicationCategoryValueSet(a valid code from Pharmacy Adjudication Category Code System) `https://fhir-ig.digital.health.nz/shared-care/ValueSet/pharmacy-adjudication-category` From this IG
ClaimResponse.item.detail.adjudication.reason | example | AdjudicationReasonCodes `http://hl7.org/fhir/ValueSet/adjudication-reason` From the FHIR Standard
ClaimResponse.addItem.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code` From the FHIR Standard
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes `http://hl7.org/fhir/ValueSet/service-place` From the FHIR Standard
ClaimResponse.addItem.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth` From the FHIR Standard
ClaimResponse.addItem.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface` From the FHIR Standard
ClaimResponse.addItem.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers` From the FHIR Standard
ClaimResponse.total.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication` From the FHIR Standard
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype` From the FHIR Standard
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes `http://hl7.org/fhir/ValueSet/payment-adjustment-reason` From the FHIR Standard
ClaimResponse.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve` From the FHIR Standard
ClaimResponse.formCode | example | Form Codes `http://hl7.org/fhir/ValueSet/forms` From the FHIR Standard
ClaimResponse.processNote.type | required | NoteType `http://hl7.org/fhir/ValueSet/note-type|4.0.1` From the FHIR Standard
ClaimResponse.processNote.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.error.code | required | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error` From the FHIR Standard

#### Constraints

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

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements(2 nested mandatory elements)

Extensions

This structure refers to these extensions:

- https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number
- https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service

Other representations of profile: CSV, Excel, Schematron