Generated Narrative: StructureDefinition SharedCareClaimResponse Name Flags Card. Type Description & Constraints ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization #xD; meta 1..1 Meta Metadata about the resource #xD; source <a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( hpi-location-url-format )">C 1..1 uri HPI Facility ID from where the record is sourced Constraints: hpi-location-url-format #xD; profile 1..1 canonical(StructureDefinition) Profiles this resource claims to conform to #xD; Slices for tag 1..* Coding Tags applied to this resource Slice: Unordered, Open by value:system #xD; tag:correlationId 1..1 Coding Tags applied to this resource #xD; system 1..1 uri Hub correlation ID system Required Pattern: https://hub.services.digital.health.nz/ns/correlation-id #xD; code 1..1 code Symbol in syntax defined by the system #xD; contained 0..0 #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier Shared Care Claim Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number #xD; identifier 1..* Identifier Business identifier(s) for the claim response #xD; system 1..1 uri The namespace for the identifier value #xD; value 1..1 string The value that is unique #xD; status 1..1 code Status of the Claim Response: active, cancelled, draft, entered-in-error #xD; type 1..1 CodeableConcept More granular claim type Binding: NZ Claim Types (extensible) #xD; subType 1..1 CodeableConcept More granular claim type Binding: NZ Claim Subtypes (extensible) #xD; created 1..1 dateTime Date & time of claim determination #xD; requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the Claim #xD; request 1..1 Reference(NZ SharedCare Claim) Reference to the Claim that was determined #xD; item 0..* BackboneElement Claim response items #xD; Slices for extension 1..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier Shared Care Claim Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number #xD; extension:productOrService 1..1 CodeableConcept Shared Care Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-product-or-service #xD; extension:reviewOutcome 0..1 (Complex) Shared Care Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-review-outcome #xD; itemSequence 1..1 positiveInt Value of the corresponding Claim.item.sequence #xD; adjudication 1..* BackboneElement Adjudication (reason, amount, quantity) for each Adjudication Value Code #xD; category 1..1 CodeableConcept Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible) #xD; reason 0..1 CodeableConcept Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible) #xD; amount 1..1 Money Monetary value of the adjudication #xD; value 0..1 decimal Non-monetary value of the adjudication #xD; detail 0..* BackboneElement Any sub-determinations of this itemSequence #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:traceNumber 0..* Identifier Shared Care Claim Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-trace-number #xD; extension:reviewOutcome 0..1 (Complex) Shared Care Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/shared-care-review-outcome #xD; detailSequence 1..1 positiveInt Value of the corresponding Claim.item.detail.sequence #xD; addItem 0..* BackboneElement Any line items added by Health NZ to the claim determination that were not in the original claim #xD; adjudication 0..* Claim-level adjudication #xD; total 0..* BackboneElement Financial total of the claim for each Adjudication Value Code #xD; payment 0..1 BackboneElement Summary of the payment being made #xD; type 1..1 CodeableConcept Payment Type Code = complete or partial Binding: Payment Type Codes (extensible) #xD; date 0..1 date Expected date of payment (if known) #xD; amount 1..1 Money Payment amount #xD; error 0..* BackboneElement Collection of errors produced during claim determination #xD; itemSequence 0..1 positiveInt Refers to itemSequence to which the error relates #xD; detailSequence 0..1 positiveInt Refers to detailSequence to which the error relates #xD; code 1..1 CodeableConcept Error code #xD; Documentation for this format
A FHIR resource profile describing the outcome of NZ generic payment claims. Note: In 4B item.adjudication, item.detail.adjudication, payment.amount, insurer are compulsory fields, but not utilized in the telehealth implementation. item.adjudication.quantity R5 is item.adjudication.value in R4B.
A FHIR resource profile describing the outcome of NZ generic payment claims
Response to a claim predetermination or preauthorization
This resource provides the adjudication details from the processing of a Claim resource.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
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.
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.
When the resource last changed - e.g. when the version changed.
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](http://hl7.org/fhir/R4/http.html#read) interaction.
HPI Facility ID from where the record is sourced
Captures the source of the record. This must contain the HPIFacilityID e.g. https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A
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.
Reference must be an HPI facility URL with format https://standards.digital.health.nz/ns/hpi-facility-id/FZZ111-A
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
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.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
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.
Security Labels from the Healthcare Privacy and Security Classification System.
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.
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.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
The system URI used by the hub to identify its correlation ID.
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.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
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.
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.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
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).
Need to refer to a particular code in the system.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
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.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
A set of rules under which this content was created
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.
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.
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
The base language in which the resource is written.
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).
Text summary of the resource, for human interpretation
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.
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.
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.
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.
Internal primary key ID for shared care claim tracking
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
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).
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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business identifier(s) for the claim response
A unique identifier assigned to this claim response.
Allows claim responses to be distinguished and referenced.
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
Identifier.system is always case sensitive.
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.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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](http://hl7.org/fhir/R4/extension-rendered-value.html). 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.
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization that issued/manages the identifier.
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.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
Status of the Claim Response: active, cancelled, draft, entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
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'.
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
A code specifying the state of the resource instance.
A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Some jurisdictions need a finer grained claim type for routing and adjudication.
claim | preauthorization | predetermination
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.
This element is required to understand the nature of the request for adjudication.
Claim, preauthorization, predetermination.
The recipient of the products and services
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.
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.
Need to record a timestamp for use by both the recipient and the issuer.
The party responsible for authorization, adjudication and reimbursement.
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.
The provider which is responsible for the claim, predetermination or preauthorization.
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.
Reference to the Claim that was determined
The outcome of the claim, predetermination, or preauthorization processing.
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).
To advise the requestor of an overall processing outcome.
A human readable description of the status of the adjudication.
Reference from the Insurer which is used in later communications which refers to this adjudication.
This value is only present on preauthorization adjudications.
On subsequent claims, the insurer may require the provider to quote this value.
Preauthorization reference effective period
The time frame during which this authorization is effective.
To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
Type of Party to be reimbursed: subscriber, provider, other.
Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
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.
The adjudication for items provided on the claim.
Validation and correction of purchase unit codes for shared care services
Adjudication result for shared care claim items
Extensions that cannot be ignored even if unrecognized
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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Value of the corresponding Claim.item.sequence
A number to uniquely reference the claim item entries.
Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
The numbers associated with notes below which apply to the adjudication of this item.
Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
Adjudication (reason, amount, quantity) for each Adjudication Value Code
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.
The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
Codified representation of adjudication outcome
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.
For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Needed to enable understanding of the context of the other information in the adjudication.
A code supporting the understanding of the adjudication result and explaining variance from expected amount.
For example may indicate that the funds for this benefit type have been exhausted.
To support understanding of variance from adjudication expectations.
Monetary amount associated with the category.
For example: amount submitted, eligible amount, co-payment, and benefit payable.
Most adjuciation categories convey a monetary amount.
A non-monetary value associated with the category. Mutually exclusive to the amount element above.
For example: eligible percentage or co-payment percentage.
Some adjudication categories convey a percentage or a fixed value.
Any sub-determinations of this itemSequence
A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
The adjudication for details provided on the claim.
Value of the corresponding Claim.item.detail.sequence
A number to uniquely reference the claim detail entry.
Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
A sub-detail adjudication of a simple product or service.
The adjudication for sub-details provided on the claim.
A number to uniquely reference the claim sub-detail entry.
Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
Any line items added by Health NZ to the claim determination that were not in the original claim
The first-tier service adjudications for payor added product or service lines.
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.
Claim items which this service line is intended to replace.
The sequence number of the details within the claim item which this line is intended to replace.
Provides references to the claim details within the claim item.
The sequence number of the sub-details within the details within the claim item which this line is intended to replace.
Provides references to the claim sub-details within the claim detail.
The providers who are authorized for the services rendered to the patient.
Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
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.
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'.
Necessary to state what was provided or done.
Item typification or modifiers codes to convey additional context for the product or service.
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.
To support inclusion of the item for adjudication or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
Needed to determine whether the service or product was provided during the term of the insurance coverage.
Place of service or where product was supplied
Where the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Place of service: pharmacy, school, prison, etc.
The number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
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.
The amount charged to the patient by the provider for a single unit.
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.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The quantity times the unit price for an additional service or product or charge.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Provides the total amount claimed for the group (if a grouper) or the line item.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
The code for the teeth, quadrant, sextant and arch.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
The code for the tooth surface and surface combinations.
The second-tier service adjudications for payor added services.
The third-tier service adjudications for payor added services.
The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Financial total of the claim for each Adjudication Value Code
Categorized monetary totals for the adjudication.
Totals for amounts submitted, co-pays, benefits payable etc.
To provide the requestor with financial totals by category for the adjudication.
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.
Needed to convey the type of total provided.
Monetary total amount associated with the category.
Needed to convey the total monetary amount.
Payment details for the adjudication of the claim.
Needed to convey references to the financial instrument that has been used if payment has been made.
Whether this represents partial or complete payment of the benefits payable.
To advise the requestor when the insurer believes all payments to have been completed.
Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
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.
To advise the requestor of adjustments applied to the payment.
Needed to clarify the monetary adjustment.
Estimated date the payment will be issued or the actual issue date of payment.
To advise the payee when payment can be expected.
Benefits payable less any payment adjustment.
Needed to provide the actual payment amount.
Issuer's unique identifier for the payment instrument.
For example: EFT number or check number.
Enable the receiver to reconcile when payment received.
A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
For whom funds are to be reserved: (Patient, Provider, None).
A code for the form to be used for printing the content.
May be needed to identify specific jurisdictional forms.
Needed to specify the specific form used for producing output for this response.
The actual form, by reference or inclusion, for printing the content or an EOB.
Needed to permit insurers to include the actual form.
Needed to include the specific form used for producing output for this response.
A note that describes or explains adjudication results in a human readable form.
Provides the insurer specific textual explanations associated with the processing.
A number to uniquely identify a note entry.
Necessary to provide a mechanism to link from adjudications.
To convey the expectation for when the text is used.
The explanation or description associated with the processing.
Required to provide human readable explanation.
A code to define the language used in the text of the note.
Only required if the language is different from the resource language.
Note text may vary from the resource defined language.
Request for additional supporting or authorizing information.
For example: professional reports, documents, images, clinical resources, or accident reports.
Need to communicate insurer request for additional information required to support the adjudication.
Financial instruments for reimbursement for the health care products and services specified on the claim.
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.
At least one insurer is required for a claim to be a claim.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
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.
To identify which coverage in the list is being used to adjudicate this claim.
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.
Required to allow the adjudicator to locate the correct policy and history within their information system.
A business agreement number established between the provider and the insurer for special business processing purposes.
Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
The result of the adjudication of the line items for the Coverage specified in this insurance.
Must not be specified when 'focal=true' for this insurance.
An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Collection of errors produced during claim determination
Errors encountered during the processing of the adjudication.
If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Need to communicate processing issues to the requestor.
Refers to itemSequence to which the error relates
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.
Refers to detailSequence to which the error relates
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.
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.
An error code, from a specified code system, which details why the claim could not be adjudicated.