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

Resource Profile: MopedVAEResponse

Official URL: https://elga.moped.at/StructureDefinition/MopedVAEResponse Version: 0.1.0
Draft as of 2025-02-20 Responsible: ELGA GmbH Computable Name: MopedVAEResponse

MOPED Profil für die Beantwortung der Versichertenanspruchserklärung VAE.

Usage:

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
Required Pattern: active
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


ele-1: All FHIR elements must have a @value or children
.... coding Σ 0..* Coding Code defined by a terminology system
ele-1: All FHIR elements must have a @value or children

Required Pattern: At least the following
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


ele-1: All FHIR elements must have a @value or children
Required Pattern: preauthorization
... patient Σ 1..1 Reference(HL7® AT Core Patient Profile) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer Σ 1..1 Reference(HL7® AT Core Organization Profile) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... requestor 1..1 Reference(HL7® AT Core Organization Profile) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... request Σ 1..1 Reference(MOPED VAERequest) Id of resource triggering adjudication
ele-1: All FHIR elements must have a @value or children
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Status der Versichertenanspruchserklärung (required)
ele-1: All FHIR elements must have a @value or children
... preAuthPeriod 0..1 Period Preauthorization reference effective period
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|5.0.0
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredPattern: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|5.0.0
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0
from the FHIR Standard
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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-4errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... type
.... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... patient 1..1 Reference(HL7® AT Core Patient Profile) The recipient of the products and services
... insurer 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 1..1 Reference(MOPED VAERequest) Id of resource triggering adjudication
... decision 0..1 CodeableConcept Result of the adjudication
Binding: Status der Versichertenanspruchserklärung (required)
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... insurance
.... coverage 1..1 Reference(MOPED Coverage) Insurance information

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
... 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

Additional BindingsPurpose
CommonLanguages Starter Set
... 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
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
... 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

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 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: preauthorization
... 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(MOPED VAERequest) 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: Status der Versichertenanspruchserklärung (required)
... 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 Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... 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

Additional BindingsPurpose
CommonLanguages Starter Set
... 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(MOPED Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
ClaimResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|5.0.0
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredPattern: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|5.0.0
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0
from the FHIR Standard
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG
ClaimResponse.event.typeexampleDatesTypeCodes
http://hl7.org/fhir/ValueSet/datestype
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaimPayeeTypeCodes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.diagnosisRelatedGroupexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ClaimResponse.item.reviewOutcome.decisionexampleClaimAdjudicationDecisionsCodes
http://hl7.org/fhir/ValueSet/claim-decision
from the FHIR Standard
ClaimResponse.item.reviewOutcome.reasonexampleClaimAdjudicationDecisionReasonCodes
http://hl7.org/fhir/ValueSet/claim-decision-reason
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySite.siteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.bodySite.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFundsReservationCodes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleFormCodes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typeextensibleNoteType
http://hl7.org/fhir/ValueSet/note-type
from the FHIR Standard
ClaimResponse.processNote.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudicationErrorCodes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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-4errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... status ?!Σ 1..1 code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.


ele-1: All FHIR elements must have a @value or children
Required Pattern: active
... type Σ 1..1 CodeableConcept More granular claim type
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.


ele-1: All FHIR elements must have a @value or children
.... coding Σ 0..* Coding Code defined by a terminology system
ele-1: All FHIR elements must have a @value or children

Required Pattern: At least the following
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... use Σ 1..1 code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.


ele-1: All FHIR elements must have a @value or children
Required Pattern: preauthorization
... patient Σ 1..1 Reference(HL7® AT Core Patient Profile) The recipient of the products and services
ele-1: All FHIR elements must have a @value or children
... created Σ 1..1 dateTime Response creation date
ele-1: All FHIR elements must have a @value or children
... insurer Σ 1..1 Reference(HL7® AT Core Organization Profile) Party responsible for reimbursement
ele-1: All FHIR elements must have a @value or children
... requestor 1..1 Reference(HL7® AT Core Organization Profile) Party responsible for the claim
ele-1: All FHIR elements must have a @value or children
... request Σ 1..1 Reference(MOPED VAERequest) Id of resource triggering adjudication
ele-1: All FHIR elements must have a @value or children
... outcome Σ 1..1 code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.


ele-1: All FHIR elements must have a @value or children
... decision Σ 0..1 CodeableConcept Result of the adjudication
Binding: Status der Versichertenanspruchserklärung (required)
ele-1: All FHIR elements must have a @value or children
... preAuthPeriod 0..1 Period Preauthorization reference effective period
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|5.0.0
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.userequiredPattern: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|5.0.0
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0
from the FHIR Standard
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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-4errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
... status 1..1 code active | cancelled | draft | entered-in-error
Required Pattern: active
... type
.... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
... patient 1..1 Reference(HL7® AT Core Patient Profile) The recipient of the products and services
... insurer 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 1..1 Reference(MOPED VAERequest) Id of resource triggering adjudication
... decision 0..1 CodeableConcept Result of the adjudication
Binding: Status der Versichertenanspruchserklärung (required)
... preAuthPeriod 0..1 Period Preauthorization reference effective period
... insurance
.... coverage 1..1 Reference(MOPED Coverage) Insurance information

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse 0..* ClaimResponse "VAEST - Status der Versichertenanspruchserklärung"
... 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

Additional BindingsPurpose
CommonLanguages Starter Set
... 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
.... VerpflegskostenBeitragsbefreiung 0..1 Coding "VKBEFR – Verpflegskosten-Beitragsbefreiung"
URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung
Binding: Befreiung für den Verpflegskostenbeitrag (required)
.... VortageanzahlAufKostenbeitrag 0..1 unsignedInt "Vortageanzahl auf Kostenbeitrag:" Zur Berechnung des Verpflegskostenbeitrags für Versicherte sowie des Kostenbeitrags für Angehörige ist die Angabe der zu berücksichtigenden Vortage erforderlich. Der Krankenversicherungsträger ist auf Grund der ihm zugänglichen Informationen in der Lage, Vorpflegetage zu berücksichtigen. Berücksichtigt werden alle stationären Aufenthalte eines Patienten innerhalb eines Kalenderjahres. Der höchste Wert, mit welchem das Feld VTAGE befüllt werden kann, ist jener Wert, für welchen maximal ein Verpflegskostenbeitrag pro Kalenderjahr zu entrichten ist. Der Maximale Höchstwert beträgt somit 28 Tage.
URL: https://elga.moped.at/StructureDefinition/moped-ext-vortageanzahlAufKostenbeitrag
... 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

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
..... version 0..1 string Version of the system - if relevant
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: institutional
..... display 0..1 string Representation defined by the system
..... userSelected 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: preauthorization
... 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(MOPED VAERequest) 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: Status der Versichertenanspruchserklärung (required)
... 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 Package billing code
Binding: ExampleDiagnosisRelatedGroupCodes (example)
... 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

Additional BindingsPurpose
CommonLanguages Starter Set
... 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(MOPED Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse 0..1 Reference(ClaimResponse) Adjudication results
... error 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
ClaimResponse.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
ClaimResponse.statusrequiredPattern: active
http://hl7.org/fhir/ValueSet/fm-status|5.0.0
from the FHIR Standard
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
from the FHIR Standard
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
from the FHIR Standard
ClaimResponse.userequiredPattern: preauthorization
http://hl7.org/fhir/ValueSet/claim-use|5.0.0
from the FHIR Standard
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/claim-outcome|5.0.0
from the FHIR Standard
ClaimResponse.decisionrequiredVAEStatus (a valid code from Status der Versichertenanspruchserklärung)
https://elga.moped.at/ValueSet/VAEStatus
from this IG
ClaimResponse.event.typeexampleDatesTypeCodes
http://hl7.org/fhir/ValueSet/datestype
from the FHIR Standard
ClaimResponse.payeeTypeexampleClaimPayeeTypeCodes
http://hl7.org/fhir/ValueSet/payeetype
from the FHIR Standard
ClaimResponse.diagnosisRelatedGroupexampleExampleDiagnosisRelatedGroupCodes
http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup
from the FHIR Standard
ClaimResponse.item.reviewOutcome.decisionexampleClaimAdjudicationDecisionsCodes
http://hl7.org/fhir/ValueSet/claim-decision
from the FHIR Standard
ClaimResponse.item.reviewOutcome.reasonexampleClaimAdjudicationDecisionReasonCodes
http://hl7.org/fhir/ValueSet/claim-decision-reason
from the FHIR Standard
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
from the FHIR Standard
ClaimResponse.addItem.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
from the FHIR Standard
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
from the FHIR Standard
ClaimResponse.addItem.bodySite.siteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
from the FHIR Standard
ClaimResponse.addItem.bodySite.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
from the FHIR Standard
ClaimResponse.addItem.detail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.revenueexampleExampleRevenueCenterCodes
http://hl7.org/fhir/ValueSet/ex-revenue-center
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrServiceEndexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
from the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
from the FHIR Standard
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
from the FHIR Standard
ClaimResponse.payment.typeexampleExamplePaymentTypeCodes
http://hl7.org/fhir/ValueSet/ex-paymenttype
from the FHIR Standard
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
from the FHIR Standard
ClaimResponse.fundsReserveexampleFundsReservationCodes
http://hl7.org/fhir/ValueSet/fundsreserve
from the FHIR Standard
ClaimResponse.formCodeexampleFormCodes
http://hl7.org/fhir/ValueSet/forms
from the FHIR Standard
ClaimResponse.processNote.typeextensibleNoteType
http://hl7.org/fhir/ValueSet/note-type
from the FHIR Standard
ClaimResponse.processNote.languagerequiredAllLanguages
http://hl7.org/fhir/ValueSet/all-languages|5.0.0
from the FHIR Standard
ClaimResponse.error.codeexampleAdjudicationErrorCodes
http://hl7.org/fhir/ValueSet/adjudication-error
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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-4errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

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