Moderne Patient:innenabrechnung und Datenkommunikation on FHIR (MOPED)
0.1.0 - ci-build
Moderne Patient:innenabrechnung und Datenkommunikation on FHIR (MOPED) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Official URL: http://example.org/StructureDefinition/MOPEDClaimResponse | Version: 0.1.0 | |||
Draft as of 2024-11-04 | Responsible: Example Publisher | Computable Name: MOPEDClaimResponse |
MOPED Profil der ClaimResponse Ressource für die Leistungsabrechnungsantwort.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
Path | Conformance | ValueSet | URI |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
Path | Conformance | ValueSet / Code | URI |
ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|5.0.0 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|5.0.0 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0 from the FHIR Standard | |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ClaimResponse | 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: AllLanguages (required): IETF language tag for a human language
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
fehlerWarnung | 0..* | (Complex) | Error/Warning URL: http://example.org/StructureDefinition/moped-ext-fehlerWarnung | |||||
diagnoseKnoten | 0..1 | Coding | "Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen. URL: http://example.org/StructureDefinition/moped-ext-diagnoseKnoten Binding: http://tbd.at/MOPED-LKFAbrechnungsKnoten (required) | |||||
lkfPunkte | 0..* | (Complex) | LKF Punkte URL: http://example.org/StructureDefinition/moped-ext-lkfPunkte | |||||
ldfPunktewertNetto | 0..1 | decimal | LDF-Punktewert Netto URL: http://example.org/StructureDefinition/moped-ext-ldfPunktewertNetto | |||||
ldfBetragNetto | 0..1 | decimal | LDF-Betrag Netto URL: http://example.org/StructureDefinition/moped-ext-ldfBetragNetto | |||||
patientenanteilAngehoerige | 0..1 | Money | Patientenanteil für Angehoerige URL: http://example.org/StructureDefinition/moped-ext-patientenanteilAngehoerige | |||||
patientenanteil | 0..1 | Money | Patientenanteil Netto URL: http://example.org/StructureDefinition/moped-ext-patientenanteil | |||||
beihilfenaequivalent | 0..1 | unsignedInt | Beihilfenaequivalent URL: http://example.org/StructureDefinition/moped-ext-beihilfenaequivalent | |||||
forderungsbetragAuslaenderverrechnungRegress | 0..1 | Money | Forderungsbetrag für Auslaenderverrechnung oder Regress URL: http://example.org/StructureDefinition/moped-ext-forderungsbetragAuslaenderverrechnungRegress | |||||
rechnungsnummerKHLGF | 0..1 | string | Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds URL: http://example.org/StructureDefinition/moped-ext-rechnungsnummerKHLGF | |||||
note | 0..* | Annotation | A recorded sex or gender property for the individual URL: http://hl7.org/fhir/StructureDefinition/note | |||||
sonderleistungsnummer | 0..1 | Coding | Sonderleistungsnummer URL: http://example.org/StructureDefinition/moped-ext-sonderleistungsnummer Binding: http://tbd.at/MOPED-Sonderleistungsnummern (required) | |||||
anzahlSonderleistungen | 0..1 | unsignedInt | Anzahl Sonderleistungen URL: http://example.org/StructureDefinition/moped-ext-anzahlSonderleistungen | |||||
punkteLDFPauschale | 0..1 | decimal | Punkte LDF Pauschale URL: http://example.org/StructureDefinition/moped-ext-punkteLDFPauschale | |||||
konstenmeldungARK | 0..1 | Coding | Kostenmeldung für (A/R/K) URL: http://example.org/StructureDefinition/moped-ext-konstenmeldungARK Binding: Kostenmeldung für (A/R/K) (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | ΣC | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional | ||||
display | ΣC | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subType | 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. Required Pattern: claim | ||||
patient | Σ | 1..1 | Reference(HL7® AT Core Patient Profile) | The recipient of the products and services | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
insurer | Σ | 1..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for reimbursement | ||||
requestor | 1..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for the claim | |||||
request | Σ | 1..1 | Reference(MOPEDClaim) | Id of resource triggering adjudication | ||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
decision | Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
event | 0..* | BackboneElement | Event 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 | ||||
type | 1..1 | CodeableConcept | Specific event Binding: DatesTypeCodes (example) | |||||
when[x] | 1..1 | Occurance date or period | ||||||
whenDateTime | dateTime | |||||||
whenPeriod | Period | |||||||
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed. | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
diagnosisRelatedGroup | 0..1 | CodeableConcept | "Abrechnung - Gruppe:" Dieses Datenfeld ist mit der Codenummer der zutreffenden Abrechnungsgruppe zu befüllen. Bei Datensätzen von stationären Krankenhausaufenthalten, die keiner leistungsorientier- ten Diagnosenfallgruppe zugeordnet werden, erfolgt ein Eintrag entsprechend der jeweiligen Aufnahmeart. Binding: http://tbd.at/MOPED-LKFAbrechnungsGruppe (required) | |||||
item | 0..* | BackboneElement | Adjudication for claim line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | BackboneElement | Adjudication results | |||||
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 | ||||
decision | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example) | |||||
reason | 0..* | CodeableConcept | Reason for result of the adjudication Binding: ClaimAdjudicationDecisionReasonCodes (example) | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
adjudication | 0..* | 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 | |||||
quantity | 0..1 | Quantity | Non-monetary value | |||||
detail | 0..* | BackboneElement | Adjudication for claim details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Detail level adjudication results | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Subdetail level adjudication results | |||||
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 | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
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 | ||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: OralSiteCodes (example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: SurfaceCodes (example) | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items adjudication results | |||||
adjudication | 0..* | 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 | ||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items detail level adjudication results | |||||
adjudication | 0..* | 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 | ||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items subdetail level adjudication results | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Added items subdetail adjudication | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 1..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: FormCodes (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 | CodeableConcept | Note purpose Binding: NoteType (extensible): The presentation types of notes. | |||||
text | 1..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: AllLanguages (required): IETF language tag for a human language
| |||||
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(SVCCoverage) | Insurance information | |||||
businessArrangement | 0..1 | string | Additional provider contract number | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
error | 0..* | BackboneElement | Processing errors | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 0..1 | positiveInt | Item sequence number | |||||
detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
code | Σ | 1..1 | CodeableConcept | Error code detailing processing issues Binding: AdjudicationErrorCodes (example): The adjudication error codes. | ||||
expression | Σ | 0..* | string | FHIRPath of element(s) related to issue | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ClaimResponse.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|5.0.0 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | |
ClaimResponse.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|5.0.0 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0 from the FHIR Standard | |
ClaimResponse.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decision from the FHIR Standard | |
ClaimResponse.event.type | example | DatesTypeCodeshttp://hl7.org/fhir/ValueSet/datestype from the FHIR Standard | |
ClaimResponse.payeeType | example | ClaimPayeeTypeCodeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe | |
ClaimResponse.item.reviewOutcome.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decision from the FHIR Standard | |
ClaimResponse.item.reviewOutcome.reason | example | ClaimAdjudicationDecisionReasonCodeshttp://hl7.org/fhir/ValueSet/claim-decision-reason from the FHIR Standard | |
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | |
ClaimResponse.addItem.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | |
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | |
ClaimResponse.addItem.bodySite.site | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | |
ClaimResponse.addItem.bodySite.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | |
ClaimResponse.addItem.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | |
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | |
ClaimResponse.fundsReserve | example | FundsReservationCodeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | |
ClaimResponse.formCode | example | FormCodeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | |
ClaimResponse.processNote.type | extensible | NoteTypehttp://hl7.org/fhir/ValueSet/note-type from the FHIR Standard | |
ClaimResponse.processNote.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
ClaimResponse.error.code | example | AdjudicationErrorCodeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from ClaimResponse
Path | Conformance | ValueSet | URI |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
Key Elements View
Path | Conformance | ValueSet / Code | URI |
ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|5.0.0 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|5.0.0 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0 from the FHIR Standard | |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
ClaimResponse | 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: AllLanguages (required): IETF language tag for a human language
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
fehlerWarnung | 0..* | (Complex) | Error/Warning URL: http://example.org/StructureDefinition/moped-ext-fehlerWarnung | |||||
diagnoseKnoten | 0..1 | Coding | "Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen. URL: http://example.org/StructureDefinition/moped-ext-diagnoseKnoten Binding: http://tbd.at/MOPED-LKFAbrechnungsKnoten (required) | |||||
lkfPunkte | 0..* | (Complex) | LKF Punkte URL: http://example.org/StructureDefinition/moped-ext-lkfPunkte | |||||
ldfPunktewertNetto | 0..1 | decimal | LDF-Punktewert Netto URL: http://example.org/StructureDefinition/moped-ext-ldfPunktewertNetto | |||||
ldfBetragNetto | 0..1 | decimal | LDF-Betrag Netto URL: http://example.org/StructureDefinition/moped-ext-ldfBetragNetto | |||||
patientenanteilAngehoerige | 0..1 | Money | Patientenanteil für Angehoerige URL: http://example.org/StructureDefinition/moped-ext-patientenanteilAngehoerige | |||||
patientenanteil | 0..1 | Money | Patientenanteil Netto URL: http://example.org/StructureDefinition/moped-ext-patientenanteil | |||||
beihilfenaequivalent | 0..1 | unsignedInt | Beihilfenaequivalent URL: http://example.org/StructureDefinition/moped-ext-beihilfenaequivalent | |||||
forderungsbetragAuslaenderverrechnungRegress | 0..1 | Money | Forderungsbetrag für Auslaenderverrechnung oder Regress URL: http://example.org/StructureDefinition/moped-ext-forderungsbetragAuslaenderverrechnungRegress | |||||
rechnungsnummerKHLGF | 0..1 | string | Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds URL: http://example.org/StructureDefinition/moped-ext-rechnungsnummerKHLGF | |||||
note | 0..* | Annotation | A recorded sex or gender property for the individual URL: http://hl7.org/fhir/StructureDefinition/note | |||||
sonderleistungsnummer | 0..1 | Coding | Sonderleistungsnummer URL: http://example.org/StructureDefinition/moped-ext-sonderleistungsnummer Binding: http://tbd.at/MOPED-Sonderleistungsnummern (required) | |||||
anzahlSonderleistungen | 0..1 | unsignedInt | Anzahl Sonderleistungen URL: http://example.org/StructureDefinition/moped-ext-anzahlSonderleistungen | |||||
punkteLDFPauschale | 0..1 | decimal | Punkte LDF Pauschale URL: http://example.org/StructureDefinition/moped-ext-punkteLDFPauschale | |||||
konstenmeldungARK | 0..1 | Coding | Kostenmeldung für (A/R/K) URL: http://example.org/StructureDefinition/moped-ext-konstenmeldungARK Binding: Kostenmeldung für (A/R/K) (required) | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | 0..* | Identifier | Business Identifier for a claim response | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active | ||||
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 0..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | id | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | ΣC | 0..1 | code | Symbol in syntax defined by the system Required Pattern: institutional | ||||
display | ΣC | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subType | 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. Required Pattern: claim | ||||
patient | Σ | 1..1 | Reference(HL7® AT Core Patient Profile) | The recipient of the products and services | ||||
created | Σ | 1..1 | dateTime | Response creation date | ||||
insurer | Σ | 1..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for reimbursement | ||||
requestor | 1..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for the claim | |||||
request | Σ | 1..1 | Reference(MOPEDClaim) | Id of resource triggering adjudication | ||||
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
decision | Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication. | ||||
disposition | 0..1 | string | Disposition Message | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
event | 0..* | BackboneElement | Event 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 | ||||
type | 1..1 | CodeableConcept | Specific event Binding: DatesTypeCodes (example) | |||||
when[x] | 1..1 | Occurance date or period | ||||||
whenDateTime | dateTime | |||||||
whenPeriod | Period | |||||||
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed. | |||||
encounter | 0..* | Reference(Encounter) | Encounters associated with the listed treatments | |||||
diagnosisRelatedGroup | 0..1 | CodeableConcept | "Abrechnung - Gruppe:" Dieses Datenfeld ist mit der Codenummer der zutreffenden Abrechnungsgruppe zu befüllen. Bei Datensätzen von stationären Krankenhausaufenthalten, die keiner leistungsorientier- ten Diagnosenfallgruppe zugeordnet werden, erfolgt ein Eintrag entsprechend der jeweiligen Aufnahmeart. Binding: http://tbd.at/MOPED-LKFAbrechnungsGruppe (required) | |||||
item | 0..* | BackboneElement | Adjudication for claim line items | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 1..1 | positiveInt | Claim item instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | BackboneElement | Adjudication results | |||||
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 | ||||
decision | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example) | |||||
reason | 0..* | CodeableConcept | Reason for result of the adjudication Binding: ClaimAdjudicationDecisionReasonCodes (example) | |||||
preAuthRef | 0..1 | string | Preauthorization reference | |||||
preAuthPeriod | 0..1 | Period | Preauthorization reference effective period | |||||
adjudication | 0..* | 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 | |||||
quantity | 0..1 | Quantity | Non-monetary value | |||||
detail | 0..* | BackboneElement | Adjudication for claim details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
detailSequence | 1..1 | positiveInt | Claim detail instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Detail level adjudication results | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
subDetail | 0..* | BackboneElement | Adjudication for claim sub-details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
subDetailSequence | 1..1 | positiveInt | Claim sub-detail instance identifier | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Subdetail level adjudication results | |||||
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 | |||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
request | 0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
bodySite | 0..* | BackboneElement | Anatomical location | |||||
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 | ||||
site | 1..* | CodeableReference(BodyStructure) | Location Binding: OralSiteCodes (example) | |||||
subSite | 0..* | CodeableConcept | Sub-location Binding: SurfaceCodes (example) | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items adjudication results | |||||
adjudication | 0..* | 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 | ||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items detail level adjudication results | |||||
adjudication | 0..* | 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 | ||||
traceNumber | 0..* | Identifier | Number for tracking | |||||
revenue | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
productOrService | 0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
productOrServiceEnd | 0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
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 | |||||
tax | 0..1 | Money | Total tax | |||||
net | 0..1 | Money | Total item cost | |||||
noteNumber | 0..* | positiveInt | Applicable note numbers | |||||
reviewOutcome | 0..1 | See reviewOutcome (ClaimResponse) | Added items subdetail level adjudication results | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Added items subdetail adjudication | |||||
adjudication | 0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
total | Σ | 0..* | BackboneElement | Adjudication totals | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
category | Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
amount | Σ | 1..1 | Money | Financial total for the category | ||||
payment | 0..1 | BackboneElement | Payment Details | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
type | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
adjustment | 0..1 | Money | Payment adjustment for non-claim issues | |||||
adjustmentReason | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
date | 0..1 | date | Expected date of payment | |||||
amount | 1..1 | Money | Payable amount after adjustment | |||||
identifier | 0..1 | Identifier | Business identifier for the payment | |||||
fundsReserve | 0..1 | CodeableConcept | Funds reserved status Binding: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
formCode | 0..1 | CodeableConcept | Printed form identifier Binding: FormCodes (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 | CodeableConcept | Note purpose Binding: NoteType (extensible): The presentation types of notes. | |||||
text | 1..1 | string | Note explanatory text | |||||
language | 0..1 | CodeableConcept | Language of the text Binding: AllLanguages (required): IETF language tag for a human language
| |||||
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(SVCCoverage) | Insurance information | |||||
businessArrangement | 0..1 | string | Additional provider contract number | |||||
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |||||
error | 0..* | BackboneElement | Processing errors | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
itemSequence | 0..1 | positiveInt | Item sequence number | |||||
detailSequence | 0..1 | positiveInt | Detail sequence number | |||||
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |||||
code | Σ | 1..1 | CodeableConcept | Error code detailing processing issues Binding: AdjudicationErrorCodes (example): The adjudication error codes. | ||||
expression | Σ | 0..* | string | FHIRPath of element(s) related to issue | ||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
ClaimResponse.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
ClaimResponse.status | required | Pattern: activehttp://hl7.org/fhir/ValueSet/fm-status|5.0.0 from the FHIR Standard | |
ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type from the FHIR Standard | |
ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtype from the FHIR Standard | |
ClaimResponse.use | required | Pattern: claimhttp://hl7.org/fhir/ValueSet/claim-use|5.0.0 from the FHIR Standard | |
ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0 from the FHIR Standard | |
ClaimResponse.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decision from the FHIR Standard | |
ClaimResponse.event.type | example | DatesTypeCodeshttp://hl7.org/fhir/ValueSet/datestype from the FHIR Standard | |
ClaimResponse.payeeType | example | ClaimPayeeTypeCodeshttp://hl7.org/fhir/ValueSet/payeetype from the FHIR Standard | |
ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe | |
ClaimResponse.item.reviewOutcome.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decision from the FHIR Standard | |
ClaimResponse.item.reviewOutcome.reason | example | ClaimAdjudicationDecisionReasonCodeshttp://hl7.org/fhir/ValueSet/claim-decision-reason from the FHIR Standard | |
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reason from the FHIR Standard | |
ClaimResponse.addItem.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-code from the FHIR Standard | |
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-place from the FHIR Standard | |
ClaimResponse.addItem.bodySite.site | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/tooth from the FHIR Standard | |
ClaimResponse.addItem.bodySite.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surface from the FHIR Standard | |
ClaimResponse.addItem.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-center from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-uscls from the FHIR Standard | |
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiers from the FHIR Standard | |
ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudication from the FHIR Standard | |
ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttype from the FHIR Standard | |
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reason from the FHIR Standard | |
ClaimResponse.fundsReserve | example | FundsReservationCodeshttp://hl7.org/fhir/ValueSet/fundsreserve from the FHIR Standard | |
ClaimResponse.formCode | example | FormCodeshttp://hl7.org/fhir/ValueSet/forms from the FHIR Standard | |
ClaimResponse.processNote.type | extensible | NoteTypehttp://hl7.org/fhir/ValueSet/note-type from the FHIR Standard | |
ClaimResponse.processNote.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0 from the FHIR Standard | |
ClaimResponse.error.code | example | AdjudicationErrorCodeshttp://hl7.org/fhir/ValueSet/adjudication-error from the FHIR Standard |
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron