Generated Narrative: StructureDefinition MopedVAEResponse Name Flags Card. Type Description & Constraints ClaimResponse ClaimResponse #xD; Slices for extension 3..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:MopedSupportingInfoSonderklasse O 1..1 (Complex) KaOrg: Allgemeine Gebührenklasse/Sonderklasse URL: https://elga.moped.at/StructureDefinition/MopedSupportingInfoSonderklasse Obligations Actor SHALL:populate Moped SV Actor #xD; extension:VerpflegskostenBeitragsbefreiung O 1..1 (Complex) KaOrg: Verpflegskosten-Beitragsbefreiung URL: https://elga.moped.at/StructureDefinition/moped-ext-verpflegskostenBeitragsbefreiung Obligations Actor SHALL:populate Moped SV Actor #xD; extension:MopedSupportingInfoVortageanzahlAufKostenbeitrag O 1..1 (Complex) KaOrg: Vortageanzahl auf Kostenbeitrag URL: https://elga.moped.at/StructureDefinition/MopedSupportingInfoVortageanzahlAufKostenbeitrag Obligations Actor SHALL:populate Moped SV Actor #xD; status O 1..1 code active | cancelled | draft | entered-in-error Required Pattern: active Obligations Actor SHALL:populate Moped SV Actor SHALL:handle Moped Device Actor #xD; type O 1..1 CodeableConcept More granular claim type Obligations Actor SHALL:populate Moped SV Actor #xD; coding 1..* Coding Code defined by a terminology system Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: institutional #xD; use O 1..1 code claim | preauthorization | predetermination Required Pattern: preauthorization Obligations Actor SHALL:populate Moped SV Actor #xD; patient O 1..1 Reference(HL7® AT Core Patient Profile) The recipient of the products and services Obligations Actor SHALL:handle Moped Device Actor #xD; insurer O 1..1 Reference(SV Organization) Party responsible for reimbursement Obligations Actor SHALL:populate Moped SV Actor #xD; requestor O 1..1 Reference(KH Organization) Party responsible for the claim Obligations Actor SHALL:handle Moped Device Actor #xD; request O 1..1 Reference(MOPED VAERequest) Id of resource triggering adjudication Obligations Actor SHALL:populate Moped SV Actor #xD; outcome O 1..1 code VAE Bewilligung/Ablehnung Obligations Actor SHALL:populate Moped SV Actor #xD; decision O 1..1 CodeableConcept KaOrg: Status der VAE Binding: Status der Versichertenanspruchserklärung (required) Obligations Actor SHALL:populate Moped SV Actor #xD; <a href="StructureDefinition-MopedVAEResponse-definitions.html#ClaimResponse.preAuthPeriod" title="Ist diese Zeitspanne angegeben so gibt es ein Fristende.#xA;Befristungen sind in folgenden Fällen vorgesehen:#xA;- Bei zeitlichen Beschränkungen aufgrund einer zu erwartenden, nachfolgenden medizini-#xA;schen Hauskrankenpflege#xA;- Bei Vorhersehbarkeit des Eintritts einer Asylierung#xA;- Bei unsicherer, versicherungsrechtlicher Entwicklung#xA;Bei den ersten beiden Punkten wird von den Krankenversicherungsträgern das Fristende individuell gesetzt. Beim dritten Punkt wird im Regelfall eine generelle Tagesbeschränkung erfolgen, weil die Versichertenanspruchserklärung in die Zukunft gerichtet ist und der Krankenversicherungsträger seine Zuständigkeit von vornherein nur für einen bestimmten Zeitraum annehmen kann (Ausleis- tungssituation gem. § 122 ASVG).#xA;Durch die Angabe eines Fristendes wird signalisiert, dass bei einem über das Fristende hinaus dau- ernden Aufenthalt eine Verlängerungsanzeige vorzulegen ist.">preAuthPeriod O 1..1 Period Preauthorization reference effective period Obligations Actor SHALL:populate Moped SV Actor #xD; start 1..1 dateTime KaOrg: VAE Beginndatum #xD; end 0..1 dateTime KaOrg: Fristende + VAE Endedatum; VAE Enddatum und Indikator, ob es ein Fristende gibt #xD; addItem #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:AddItemCategory O 0..1 CodeableConcept AddItemCategory URL: https://elga.moped.at/StructureDefinition/moped-ext-AddItemCategory Binding: Moped Claim Item Category ValueSet (required) Obligations Actor SHALL:populate Moped SV Actor #xD; Documentation for this format
MOPED Profil für die Beantwortung der Versichertenanspruchserklärung VAE.
Response to a claim predetermination or preauthorization
This resource provides the adjudication details from the processing of a Claim resource.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
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()
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()
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies its meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
KaOrg: Allgemeine Gebührenklasse/Sonderklasse
Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues
KaOrg: Verpflegskosten-Beitragsbefreiung
VKBEFR – Verpflegskosten-Beitragsbefreiung
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R5/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business Identifier for a claim response
A unique identifier assigned to this claim response.
Allows claim responses to be distinguished and referenced.
Trace number for tracking purposes. May be defined at the jurisdiction level or between trading partners.
Allows partners to uniquely identify components for tracking.
active | cancelled | draft | entered-in-error
This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.
Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.
This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
A code specifying the state of the resource instance.
A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.
This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.
Some jurisdictions need a finer grained claim type for routing and adjudication.
The type or discipline-style of the claim.
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
claim | preauthorization | predetermination
A code to indicate whether the nature of the request is: Claim - A request to an Insurer to adjudicate the supplied charges for health care goods and services under the identified policy and to pay the determined Benefit amount, if any; Preauthorization - A request to an Insurer to adjudicate the supplied proposed future charges for health care goods and services under the identified policy and to approve the services and provide the expected benefit amounts and potentially to reserve funds to pay the benefits when Claims for the indicated services are later submitted; or, Pre-determination - A request to an Insurer to adjudicate the supplied 'what if' charges for health care goods and services under the identified policy and report back what the Benefit payable would be had the services actually been provided.
This element is required to understand the nature of the request for adjudication.
Claim, preauthorization, predetermination.
The recipient of the products and services
The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.
The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.
Need to record a timestamp for use by both the recipient and the issuer.
The party responsible for authorization, adjudication and reimbursement.
To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.
The provider which is responsible for the claim, predetermination or preauthorization.
Typically this field would be 1..1 where this party is accountable for the data content within the claim but is not necessarily the facility, provider group or practitioner who provided the products and services listed within this claim resource. This field is the Billing Provider, for example, a facility, provider group, lab or practitioner..
The outcome of the claim, predetermination, or preauthorization processing.
The resource may be used to indicate that the Claim/Preauthorization/Pre-determination has been received but processing has not begun (queued); that it has been processed and one or more errors have been detected (error); no errors were detected and some of the adjudication processing has been performed (partial); or all of the adjudication processing has completed without errors (complete).
To advise the requestor of an overall processing outcome.
"VAEST - Status der Versichertenanspruchserklärung"
The element is used to indicate the current state of the adjudication overall for the claim resource, for example: the request has been held (pended) for adjudication processing, for manual review or other reasons; that it has been processed and will be paid, or the outstanding paid, as submitted (approved); that no amount will be paid (denied); or that some amount between zero and the submitted amount will be paid (partial).
To advise the requestor of the result of the adjudication process.
A human readable description of the status of the adjudication.
Reference from the Insurer which is used in later communications which refers to this adjudication.
This value is only present on preauthorization adjudications.
On subsequent claims, the insurer may require the provider to quote this value.
Preauthorization reference effective period
Ist diese Zeitspanne angegeben so gibt es ein Fristende. Befristungen sind in folgenden Fällen vorgesehen: - Bei zeitlichen Beschränkungen aufgrund einer zu erwartenden, nachfolgenden medizini- schen Hauskrankenpflege - Bei Vorhersehbarkeit des Eintritts einer Asylierung - Bei unsicherer, versicherungsrechtlicher Entwicklung Bei den ersten beiden Punkten wird von den Krankenversicherungsträgern das Fristende individuell gesetzt. Beim dritten Punkt wird im Regelfall eine generelle Tagesbeschränkung erfolgen, weil die Versichertenanspruchserklärung in die Zukunft gerichtet ist und der Krankenversicherungsträger seine Zuständigkeit von vornherein nur für einen bestimmten Zeitraum annehmen kann (Ausleis- tungssituation gem. § 122 ASVG). Durch die Angabe eines Fristendes wird signalisiert, dass bei einem über das Fristende hinaus dau- ernden Aufenthalt eine Verlängerungsanzeige vorzulegen ist.
To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.
The start of the period. The boundary is inclusive.
If the low element is missing, the meaning is that the low boundary is not known.
KaOrg: Fristende + VAE Endedatum; VAE Enddatum und Indikator, ob es ein Fristende gibt
The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.
The end value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
If the end of the period is missing, it means that the period is ongoing
Information code for an event with a corresponding date or period.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A coded event such as when a service is expected or a card printed.
A date or period in the past or future indicating when the event occurred or is expectd to occur.
Type of Party to be reimbursed: subscriber, provider, other.
Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.
Encounters associated with the listed treatments
Healthcare encounters related to this claim.
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.
Used in some jurisdictions to link clinical events to claim items.
A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.
For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.
Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.
A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.
The adjudication for items provided on the claim.
A number to uniquely reference the claim item entries.
Necessary to provide a mechanism to link the adjudication result to the submitted claim item.
The numbers associated with notes below which apply to the adjudication of this item.
Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.
The high-level results of the adjudication if adjudication has been performed.
The result of the claim, predetermination, or preauthorization adjudication.
The reasons for the result of the claim, predetermination, or preauthorization adjudication.
To advise the requestor of the contributors to the result of the adjudication process.
The time frame during which this authorization is effective.
If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.
The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.
A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item.
For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.
Needed to enable understanding of the context of the other information in the adjudication.
A code supporting the understanding of the adjudication result and explaining variance from expected amount.
For example may indicate that the funds for this benefit type have been exhausted.
To support understanding of variance from adjudication expectations.
Monetary amount associated with the category.
For example: amount submitted, eligible amount, co-payment, and benefit payable.
Most adjudication categories convey a monetary amount.
A non-monetary value associated with the category. Mutually exclusive to the amount element above.
For example: eligible percentage or co-payment percentage.
Some adjudication categories convey a percentage or a fixed value.
A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.
The adjudication for details provided on the claim.
A number to uniquely reference the claim detail entry.
Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.
A sub-detail adjudication of a simple product or service.
The adjudication for sub-details provided on the claim.
A number to uniquely reference the claim sub-detail entry.
Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.
The first-tier service adjudications for payor added product or service lines.
Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.
Claim items which this service line is intended to replace.
The sequence number of the details within the claim item which this line is intended to replace.
Provides references to the claim details within the claim item.
The sequence number of the sub-details within the details within the claim item which this line is intended to replace.
Provides references to the claim sub-details within the claim detail.
The providers who are authorized for the services rendered to the patient.
Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.
The type of revenue or cost center providing the product and/or service.
Needed in the processing of institutional claims.
Codes for the revenue or cost centers supplying the service and/or products.
When the value is a group code then this item collects a set of related item details, otherwise this contains the product, service, drug or other billing code for the item. This element may be the start of a range of .productOrService codes used in conjunction with .productOrServiceEnd or it may be a solo element where .productOrServiceEnd is not used.
If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.
Necessary to state what was provided or done.
This contains the end of a range of product, service, drug or other billing codes for the item. This element is not used when the .productOrService is a group code. This value may only be present when a .productOfService code has been provided to convey the start of the range. Typically this value may be used only with preauthorizations and not with claims.
End of a range of Drug Code; Bill Code; Service Cod
Request or Referral for Goods or Service to be rendered.
May identify the service to be provided or provider authorization for the service.
Item typification or modifiers codes to convey additional context for the product or service.
For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.
To support inclusion of the item for adjudication or to charge an elevated fee.
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
Program the product or service is provided under
Identifies the program under which this may be recovered.
For example: Neonatal program, child dental program or drug users recovery program.
Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.
Date or dates of service or product delivery
The date or dates when the service or product was supplied, performed or completed.
Needed to determine whether the service or product was provided during the term of the insurance coverage.
Place of service or where product was supplied
Where the product or service was provided.
The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.
Place of service: pharmacy, school, prison, etc.
The number of repetitions of a service or product.
Required when the product or service code does not convey the quantity provided.
If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.
The amount charged to the patient by the provider for a single unit.
A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.
To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).
When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.
The total of taxes applicable for this product or service.
Required when taxes are not embedded in the unit price or provided as a separate service.
The total amount claimed for the group (if a grouper) or the addItem. Net = unit price * quantity * factor.
For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.
Provides the total amount claimed for the group (if a grouper) or the line item.
Physical location where the service is performed or applies.
Physical service site on the patient (limb, tooth, etc.).
For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.
Allows insurer to validate specific procedures.
A region or surface of the bodySite, e.g. limb region or tooth surface(s).
The second-tier service adjudications for payor added services.
The total amount claimed for the group (if a grouper) or the addItem.detail. Net = unit price * quantity * factor.
Added items detail level adjudication results
The third-tier service adjudications for payor added services.
The total amount claimed for the addItem.detail.subDetail. Net = unit price * quantity * factor.
Added items subdetail level adjudication results
The adjudication results which are presented at the header level rather than at the line-item or add-item levels.
Some insurers will receive line-items but provide the adjudication only at a summary or header-level.
Categorized monetary totals for the adjudication.
Totals for amounts submitted, co-pays, benefits payable etc.
To provide the requestor with financial totals by category for the adjudication.
A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item.
Needed to convey the type of total provided.
Monetary total amount associated with the category.
Needed to convey the total monetary amount.
Payment details for the adjudication of the claim.
Needed to convey references to the financial instrument that has been used if payment has been made.
Whether this represents partial or complete payment of the benefits payable.
To advise the requestor when the insurer believes all payments to have been completed.
The type (partial, complete) of the payment.
Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.
Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider.
To advise the requestor of adjustments applied to the payment.
Needed to clarify the monetary adjustment.
Estimated date the payment will be issued or the actual issue date of payment.
To advise the payee when payment can be expected.
Benefits payable less any payment adjustment.
Needed to provide the actual payment amount.
Issuer's unique identifier for the payment instrument.
For example: EFT number or check number.
Enable the receiver to reconcile when payment received.
A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.
Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.
Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.
For whom funds are to be reserved: (Patient, Provider, None).
A code for the form to be used for printing the content.
May be needed to identify specific jurisdictional forms.
Needed to specify the specific form used for producing output for this response.
The actual form, by reference or inclusion, for printing the content or an EOB.
Needed to permit insurers to include the actual form.
Needed to include the specific form used for producing output for this response.
A note that describes or explains adjudication results in a human readable form.
Provides the insurer specific textual explanations associated with the processing.
A number to uniquely identify a note entry.
Necessary to provide a mechanism to link from adjudications.
To convey the expectation for when the text is used.
The explanation or description associated with the processing.
Required to provide human readable explanation.
A code to define the language used in the text of the note.
Only required if the language is different from the resource language.
Note text may vary from the resource defined language.
Request for additional supporting or authorizing information.
For example: professional reports, documents, images, clinical resources, or accident reports.
Need to communicate insurer request for additional information required to support the adjudication.
Financial instruments for reimbursement for the health care products and services specified on the claim.
All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.
At least one insurer is required for a claim to be a claim.
A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.
A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.
A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.
To identify which coverage in the list is being used to adjudicate this claim.
Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.
Required to allow the adjudicator to locate the correct policy and history within their information system.
A business agreement number established between the provider and the insurer for special business processing purposes.
Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.
The result of the adjudication of the line items for the Coverage specified in this insurance.
Must not be specified when 'focal=true' for this insurance.
An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.
Errors encountered during the processing of the adjudication.
If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.
Need to communicate processing issues to the requestor.
The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.
An error code, from a specified code system, which details why the claim could not be adjudicated.
A [simple subset of FHIRPath](http://hl7.org/fhir/R5/fhirpath.html#simple) limited to element names, repetition indicators and the default child accessor that identifies one of the elements in the resource that caused this issue to be raised.
The root of the FHIRPath is the resource or bundle that generated OperationOutcome. Each FHIRPath SHALL resolve to a single node.
Allows systems to highlight or otherwise guide users to elements implicated in issues to allow them to be fixed more easily.