This resource provides the adjudication details from the processing of a Claim resource.

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.

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.

An Extension

MOPED Extension für akzeptierte Errors und Warnings

"Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen.

"Zusatzpunkte Belagsdauerausreißer nach oben:" In dieses Datenfeld ist – soweit zutreffend – die Summe der tageweise ermittelten Zusatz- punkte für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufenthaltes über der im LKF-Modell in der jeweiligen LDF-Pauschale fest- gelegten Belagsdauerobergrenze liegt.

"Zusatzpunkte Intensiv:" In dieses Datenfeld ist – soweit zutreffend – die Summe der Zusatzpunkte für während des stationären Krankenhausaufenthalts angefallene Tage auf abrechnungsrelevanten Intensiveinheiten einzutragen.

"Zusatzpunkte Mehrfachleistungen:" In dieses Datenfeld ist – soweit zutreffend – die Summe der Zusatzpunkte für zusätzliche Leistungen außerhalb des Punktepauschales der zur Abrechnung gelangenden Gruppe einzutragen.

"Punkte spezieller Bereiche (tageweise):" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Tageskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Punkte total:" In dieses Datenfeld ist die Gesamtsumme der für den stationären Aufenthalt/den ambulanten Besuch ermittelten Punkte einzutragen.

MOPED Extension für den LDF-Punktewert Netto

MOPED Extension für den LDF-Punktewert Netto. Ergibt sich durch Punkteanzahl mal Punktewert Forderungsbasis ohne Berücksichtigung eines Patientenanteiles f. Angehörige bzw. eines Beihilfenäquivalentes

MOPED Extension für den Patientenanteil für Angehörige (tägl. Satz) netto: Betrag in €, 2 Nachkommastellen

MOPED Extension für den Patientenanteil netto: Betrag in €, 2 Nachkommastellen

MOPED Extension für das Beihilfenaequivalent

MOPED Extension für den Forderungsbetrag für Ausländerverrechnung oder Regress

MOPED Extension für die Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds

Additional notes that apply to this resource or element.

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

"Leistungskomponente/Leistungspunkte:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Leistungskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Tageskomponente/Kontaktpunkte:" In dieses Datenfeld ist – soweit zutreffend – die Tageskomponente bzw. sind die Kontakt- punkte einzutragen.

MOPED Extension für die Sonderleistungsnummer

MOPED Extension für die Anzahl der Sonderleistungen

MOPED Extension für die LDF Punkte Pauschale

MOPED Extension für die Kostenmeldung. Konstenmeldung für A = Ausländerverrechnung, R = Regressangelegenheiten oder K = Kosteninformation

"Punkte Belagsdauerausreisser unten - Leistungskomponente:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Leistungskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Punkte Belagsdauerausreisser unten - Tageskomponente:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Tageskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

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.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

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'.

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.

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

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.

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

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.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

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..

Original request resource reference.

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).

The result of the claim processing.

To advise the requestor of an overall processing outcome.

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.

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.

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.

This resource provides the adjudication details from the processing of a Claim resource.

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.

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.

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).

IETF language tag for a human language

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.

An Extension

MOPED Extension für akzeptierte Errors und Warnings

"Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen.

"Zusatzpunkte Belagsdauerausreißer nach oben:" In dieses Datenfeld ist – soweit zutreffend – die Summe der tageweise ermittelten Zusatz- punkte für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufenthaltes über der im LKF-Modell in der jeweiligen LDF-Pauschale fest- gelegten Belagsdauerobergrenze liegt.

"Zusatzpunkte Intensiv:" In dieses Datenfeld ist – soweit zutreffend – die Summe der Zusatzpunkte für während des stationären Krankenhausaufenthalts angefallene Tage auf abrechnungsrelevanten Intensiveinheiten einzutragen.

"Zusatzpunkte Mehrfachleistungen:" In dieses Datenfeld ist – soweit zutreffend – die Summe der Zusatzpunkte für zusätzliche Leistungen außerhalb des Punktepauschales der zur Abrechnung gelangenden Gruppe einzutragen.

"Punkte spezieller Bereiche (tageweise):" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Tageskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Punkte total:" In dieses Datenfeld ist die Gesamtsumme der für den stationären Aufenthalt/den ambulanten Besuch ermittelten Punkte einzutragen.

MOPED Extension für den LDF-Punktewert Netto

MOPED Extension für den LDF-Punktewert Netto. Ergibt sich durch Punkteanzahl mal Punktewert Forderungsbasis ohne Berücksichtigung eines Patientenanteiles f. Angehörige bzw. eines Beihilfenäquivalentes

MOPED Extension für den Patientenanteil für Angehörige (tägl. Satz) netto: Betrag in €, 2 Nachkommastellen

MOPED Extension für den Patientenanteil netto: Betrag in €, 2 Nachkommastellen

MOPED Extension für das Beihilfenaequivalent

MOPED Extension für den Forderungsbetrag für Ausländerverrechnung oder Regress

MOPED Extension für die Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds

Additional notes that apply to this resource or element.

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

"Leistungskomponente/Leistungspunkte:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Leistungskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Tageskomponente/Kontaktpunkte:" In dieses Datenfeld ist – soweit zutreffend – die Tageskomponente bzw. sind die Kontakt- punkte einzutragen.

MOPED Extension für die Sonderleistungsnummer

MOPED Extension für die Anzahl der Sonderleistungen

MOPED Extension für die LDF Punkte Pauschale

MOPED Extension für die Kostenmeldung. Konstenmeldung für A = Ausländerverrechnung, R = Regressangelegenheiten oder K = Kosteninformation

"Punkte Belagsdauerausreisser unten - Leistungskomponente:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Leistungskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

"Punkte Belagsdauerausreisser unten - Tageskomponente:" In dieses Datenfeld ist – soweit zutreffend – die ermittelte Tageskomponente für jene Patient:innen einzutragen, deren Belagsdauer des akut-stationären Krankenhausaufent- halts unter der im LKF-Modell in der jeweiligen LDF-Pauschale festgelegten Belagsdauer- untergrenze liegt.

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.

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.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

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'.

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.

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

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.

A more granular claim typecode.

Some jurisdictions need a finer grained claim type for routing and adjudication.

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.

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

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.

The date this resource was created.

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..

Original request resource reference.

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).

The result of the claim processing.

To advise the requestor of an overall processing outcome.