Moderne Patient:innenabrechnung und Datenkommunikation on FHIR (MOPED)
0.1.0 - ci-build
Moderne Patient:innenabrechnung und Datenkommunikation on FHIR (MOPED)
0.1.0 - ci-build
Moderne Patient:innenabrechnung und Datenkommunikation on FHIR (MOPED) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://example.org/StructureDefinition/MOPEDClaimResponse | Version: 0.1.0 | |||
| Draft as of 2024-09-12 | Responsible: Example Publisher | Computable Name: MOPEDClaimResponse | ||
MOPED Profil der ClaimResponse Ressource für die Leistungsabrechnungsantwort.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ClaimResponse
| Path | Conformance | ValueSet | URI |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
| Path | Conformance | ValueSet | URI |
| ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|5.0.0from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|5.0.0from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0from the FHIR Standard | |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  ClaimResponse |
0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |||||
  id |
Σ | 0..1 | id | Logical id of this artifact | ||||
 meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
   ErrorWarning |
0..* | (Complex) | Error/Warning URL: http://example.org/StructureDefinition/moped-ext-ErrorWarning | |||||
| DiagnosisRelatedNode |
0..1 | code | "Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen. URL: http://example.org/StructureDefinition/moped-ext-diagnosisRelatedNode Binding: http://tbd.at/MOPED-LKFAbrechnungsKnoten (required) | |||||
| ZusatzpunkteBelagsdauerausreisserNachOben |
0..1 | unsignedInt | Zusatzpunkte Belagsdauerausreißer nach oben URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Belagsdauerausreisser-nach-oben | |||||
| ZusatzpunkteIntensiv |
0..1 | unsignedInt | Zusatzpunkte Intensiv URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Intensiv | |||||
| ZusatzpunkteMehrfachleistungen |
0..1 | unsignedInt | Zusatzpunkte Mehrfachleistungen URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Mehrfachleistungen | |||||
| PunkteSpeziellerBereicheTageweise |
0..1 | unsignedInt | Punkte spezieller Bereiche (tageweise) URL: http://example.org/StructureDefinition/Punkte-spezieller-Bereiche-tageweise | |||||
| TotalPoints |
0..1 | unsignedInt | Punkte total URL: http://example.org/StructureDefinition/totalPoints | |||||
| LDFPunktewertNetto |
0..1 | decimal | LDF-Punktewert Netto URL: http://example.org/StructureDefinition/moped-ext-LDFPunktewertNetto | |||||
| LDFBetragNetto |
0..1 | decimal | LDF-Betrag Netto URL: http://example.org/StructureDefinition/moped-ext-LDFBetragNetto | |||||
| PatientenanteilAngehoerige |
0..1 | Money | Patientenanteil für Angehoerige URL: http://example.org/StructureDefinition/moped-ext-PatientenanteilAngehoerige | |||||
| Patientenanteil |
0..1 | Money | Patientenanteil Netto URL: http://example.org/StructureDefinition/moped-ext-Patientenanteil | |||||
| Beihilfenaequivalent |
0..1 | unsignedInt | Beihilfenaequivalent URL: http://example.org/StructureDefinition/moped-ext-Beihilfenaequivalent | |||||
| ForderungsbetragAuslaenderverrechnungRegress |
0..1 | Money | Forderungsbetrag für Auslaenderverrechnung oder Regress URL: http://example.org/StructureDefinition/moped-ext-ForderungsbetragAuslaenderverrechnungRegress | |||||
| RechnungsnummerKHLGF |
0..1 | string | Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds URL: http://example.org/StructureDefinition/moped-ext-RechnungsnummerKHLGF | |||||
| Note |
0..* | Annotation | A recorded sex or gender property for the individual URL: http://hl7.org/fhir/StructureDefinition/note | |||||
| LeistungskomponenteLeistungspunkte |
0..1 | unsignedInt | Leistungskomponente/Leistungspunkte URL: http://example.org/StructureDefinition/Leistungskomponente-Leistungspunkte | |||||
| TageskomponenteKontaktpunkte |
0..1 | unsignedInt | Tageskomponente/Kontaktpunkte URL: http://example.org/StructureDefinition/Tageskomponente-Kontaktpunkte | |||||
| Sonderleistungsnummer |
0..1 | code | Sonderleistungsnummer URL: http://example.org/StructureDefinition/moped-ext-Sonderleistungsnummer Binding: http://tbd.at/MOPED-Sonderleistungsnummern (required) | |||||
| AnzahlSonderleistungen |
0..1 | unsignedInt | Anzahl Sonderleistungen URL: http://example.org/StructureDefinition/moped-ext-AnzahlSonderleistungen | |||||
| PunkteLDFPauschale |
0..1 | decimal | Punkte LDF Pauschale URL: http://example.org/StructureDefinition/moped-ext-PunkteLDFPauschale | |||||
| KonstenmeldungARK |
0..1 | code | Kostenmeldung für (A/R/K) URL: http://example.org/StructureDefinition/moped-ext-KonstenmeldungARK Binding: Kostenmeldung für (A/R/K) (required) | |||||
| PunkteBelagsdauerausreisserUntenLeistungskomponente |
0..1 | unsignedInt | Punkte Belagsdauerausreisser unten - Leistungskomponente URL: http://example.org/StructureDefinition/Punkte-Belagsdauerausreisser-unten-Leistungskomponente | |||||
 PunkteBelagsdauerausreisserUntenTageskomponente |
0..1 | unsignedInt | Punkte Belagsdauerausreisser unten - Tageskomponente URL: http://example.org/StructureDefinition/Punkte-Belagsdauerausreisser-unten-Tageskomponente | |||||
 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. | ||||
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| 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. | ||||
 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 | 0..1 | Reference(Organization) | Party responsible for reimbursement | ||||
| requestor |
0..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for the claim | |||||
| request |
Σ | 0..1 | Reference(MOPEDClaim) | Id of resource triggering adjudication | ||||
| outcome |
Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| decision |
Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication. | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
0..1 | Period | Preauthorization reference effective period | |||||
| event |
0..* | BackboneElement | Event information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Specific event Binding: DatesTypeCodes (example) | |||||
  when[x] |
1..1 | Occurance date or period | ||||||
 whenDateTime |
dateTime | |||||||
 whenPeriod |
Period | |||||||
| payeeType |
0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed. | |||||
 Slices for encounter |
0..* | Reference(Encounter) | Encounters associated with the listed treatments Slice: Unordered, Open by | |||||
| encounter:MopedEncounter |
0..1 | Reference(MOPEDEncounter) | Generelle Informationen zu Aufnahme und Entlassung des Patienten | |||||
| encounter:TransferEncounter |
0..* | Reference(MOPEDTransferEncounter) | Informationen zu Verlegungen innerhalb oder zwischen Krankenanstalten | |||||
| diagnosisRelatedGroup |
0..1 | CodeableConcept | "Abrechnung - Gruppe:" Dieses Datenfeld ist mit der Codenummer der zutreffenden Abrechnungsgruppe zu befüllen. Bei Datensätzen von stationären Krankenhausaufenthalten, die keiner leistungsorientier- ten Diagnosenfallgruppe zugeordnet werden, erfolgt ein Eintrag entsprechend der jeweiligen Aufnahmeart. Binding: http://tbd.at/MOPED-LKFAbrechnungsGruppe (required) | |||||
| item |
0..* | BackboneElement | Adjudication for claim line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
1..1 | positiveInt | Claim item instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | BackboneElement | Adjudication results | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| decision |
0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example) | |||||
| reason |
0..* | CodeableConcept | Reason for result of the adjudication Binding: ClaimAdjudicationDecisionReasonCodes (example) | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
0..1 | Period | Preauthorization reference effective period | |||||
| adjudication |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| quantity |
0..1 | Quantity | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Adjudication for claim details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence |
1..1 | positiveInt | Claim detail instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
 reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Detail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence |
1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Subdetail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..* | positiveInt | Item sequence number | |||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| provider |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| request |
0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..* | BackboneElement | Anatomical location | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| site |
1..* | CodeableReference(BodyStructure) | Location Binding: OralSiteCodes (example) | |||||
| subSite |
0..* | CodeableConcept | Sub-location Binding: SurfaceCodes (example) | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail |
0..* | BackboneElement | Insurer added line details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items detail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items subdetail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items subdetail adjudication | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
1..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: FormCodes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | CodeableConcept | Note purpose Binding: NoteType (extensible): The presentation types of notes. | |||||
| text |
1..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| communicationRequest |
0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance |
0..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Insurance instance identifier | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI |
| ClaimResponse.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|5.0.0from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | |
| ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|5.0.0from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0from the FHIR Standard | |
| ClaimResponse.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decisionfrom the FHIR Standard | |
| ClaimResponse.event.type | example | DatesTypeCodeshttp://hl7.org/fhir/ValueSet/datestypefrom the FHIR Standard | |
| ClaimResponse.payeeType | example | ClaimPayeeTypeCodeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe | |
| ClaimResponse.item.reviewOutcome.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decisionfrom the FHIR Standard | |
| ClaimResponse.item.reviewOutcome.reason | example | ClaimAdjudicationDecisionReasonCodeshttp://hl7.org/fhir/ValueSet/claim-decision-reasonfrom the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | |
| ClaimResponse.addItem.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | |
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | |
| ClaimResponse.addItem.bodySite.site | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | |
| ClaimResponse.addItem.bodySite.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | |
| ClaimResponse.addItem.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | |
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | |
| ClaimResponse.fundsReserve | example | FundsReservationCodeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | |
| ClaimResponse.formCode | example | FormCodeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | |
| ClaimResponse.processNote.type | extensible | NoteTypehttp://hl7.org/fhir/ValueSet/note-typefrom the FHIR Standard | |
| ClaimResponse.processNote.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| ClaimResponse.error.code | example | AdjudicationErrorCodeshttp://hl7.org/fhir/ValueSet/adjudication-errorfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClaimResponse
Summary
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ClaimResponse
| Path | Conformance | ValueSet | URI |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
Key Elements View
| Path | Conformance | ValueSet | URI |
| ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|5.0.0from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|5.0.0from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0from the FHIR Standard | |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| ClaimResponse |
0..* | ClaimResponse | Response to a claim predetermination or preauthorization | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| ErrorWarning |
0..* | (Complex) | Error/Warning URL: http://example.org/StructureDefinition/moped-ext-ErrorWarning | |||||
| DiagnosisRelatedNode |
0..1 | code | "Abrechnung - Knoten:" Lukriert die Patient:innen über eine reguläre Gruppe Punkte, so ist in diesem Datenfeld die entsprechende Knotenbezeichnung einzutragen. URL: http://example.org/StructureDefinition/moped-ext-diagnosisRelatedNode Binding: http://tbd.at/MOPED-LKFAbrechnungsKnoten (required) | |||||
| ZusatzpunkteBelagsdauerausreisserNachOben |
0..1 | unsignedInt | Zusatzpunkte Belagsdauerausreißer nach oben URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Belagsdauerausreisser-nach-oben | |||||
| ZusatzpunkteIntensiv |
0..1 | unsignedInt | Zusatzpunkte Intensiv URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Intensiv | |||||
| ZusatzpunkteMehrfachleistungen |
0..1 | unsignedInt | Zusatzpunkte Mehrfachleistungen URL: http://example.org/StructureDefinition/moped-ext-Zusatzpunkte-Mehrfachleistungen | |||||
| PunkteSpeziellerBereicheTageweise |
0..1 | unsignedInt | Punkte spezieller Bereiche (tageweise) URL: http://example.org/StructureDefinition/Punkte-spezieller-Bereiche-tageweise | |||||
| TotalPoints |
0..1 | unsignedInt | Punkte total URL: http://example.org/StructureDefinition/totalPoints | |||||
| LDFPunktewertNetto |
0..1 | decimal | LDF-Punktewert Netto URL: http://example.org/StructureDefinition/moped-ext-LDFPunktewertNetto | |||||
| LDFBetragNetto |
0..1 | decimal | LDF-Betrag Netto URL: http://example.org/StructureDefinition/moped-ext-LDFBetragNetto | |||||
| PatientenanteilAngehoerige |
0..1 | Money | Patientenanteil für Angehoerige URL: http://example.org/StructureDefinition/moped-ext-PatientenanteilAngehoerige | |||||
| Patientenanteil |
0..1 | Money | Patientenanteil Netto URL: http://example.org/StructureDefinition/moped-ext-Patientenanteil | |||||
| Beihilfenaequivalent |
0..1 | unsignedInt | Beihilfenaequivalent URL: http://example.org/StructureDefinition/moped-ext-Beihilfenaequivalent | |||||
| ForderungsbetragAuslaenderverrechnungRegress |
0..1 | Money | Forderungsbetrag für Auslaenderverrechnung oder Regress URL: http://example.org/StructureDefinition/moped-ext-ForderungsbetragAuslaenderverrechnungRegress | |||||
| RechnungsnummerKHLGF |
0..1 | string | Rechnungsnummer der Krankenanstalt bzw. des Landesgesundheitsfonds URL: http://example.org/StructureDefinition/moped-ext-RechnungsnummerKHLGF | |||||
| Note |
0..* | Annotation | A recorded sex or gender property for the individual URL: http://hl7.org/fhir/StructureDefinition/note | |||||
| LeistungskomponenteLeistungspunkte |
0..1 | unsignedInt | Leistungskomponente/Leistungspunkte URL: http://example.org/StructureDefinition/Leistungskomponente-Leistungspunkte | |||||
| TageskomponenteKontaktpunkte |
0..1 | unsignedInt | Tageskomponente/Kontaktpunkte URL: http://example.org/StructureDefinition/Tageskomponente-Kontaktpunkte | |||||
| Sonderleistungsnummer |
0..1 | code | Sonderleistungsnummer URL: http://example.org/StructureDefinition/moped-ext-Sonderleistungsnummer Binding: http://tbd.at/MOPED-Sonderleistungsnummern (required) | |||||
| AnzahlSonderleistungen |
0..1 | unsignedInt | Anzahl Sonderleistungen URL: http://example.org/StructureDefinition/moped-ext-AnzahlSonderleistungen | |||||
| PunkteLDFPauschale |
0..1 | decimal | Punkte LDF Pauschale URL: http://example.org/StructureDefinition/moped-ext-PunkteLDFPauschale | |||||
| KonstenmeldungARK |
0..1 | code | Kostenmeldung für (A/R/K) URL: http://example.org/StructureDefinition/moped-ext-KonstenmeldungARK Binding: Kostenmeldung für (A/R/K) (required) | |||||
| PunkteBelagsdauerausreisserUntenLeistungskomponente |
0..1 | unsignedInt | Punkte Belagsdauerausreisser unten - Leistungskomponente URL: http://example.org/StructureDefinition/Punkte-Belagsdauerausreisser-unten-Leistungskomponente | |||||
| PunkteBelagsdauerausreisserUntenTageskomponente |
0..1 | unsignedInt | Punkte Belagsdauerausreisser unten - Tageskomponente URL: http://example.org/StructureDefinition/Punkte-Belagsdauerausreisser-unten-Tageskomponente | |||||
| 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. | ||||
| type |
Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. | ||||
| 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. | ||||
| 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 | 0..1 | Reference(Organization) | Party responsible for reimbursement | ||||
| requestor |
0..1 | Reference(HL7® AT Core Organization Profile) | Party responsible for the claim | |||||
| request |
Σ | 0..1 | Reference(MOPEDClaim) | Id of resource triggering adjudication | ||||
| outcome |
Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. | ||||
| decision |
Σ | 0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example): The overall result of the claim adjudication. | ||||
| disposition |
0..1 | string | Disposition Message | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
0..1 | Period | Preauthorization reference effective period | |||||
| event |
0..* | BackboneElement | Event information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Specific event Binding: DatesTypeCodes (example) | |||||
| when[x] |
1..1 | Occurance date or period | ||||||
| whenDateTime |
dateTime | |||||||
| whenPeriod |
Period | |||||||
| payeeType |
0..1 | CodeableConcept | Party to be paid any benefits payable Binding: ClaimPayeeTypeCodes (example): A code for the party to be reimbursed. | |||||
| Slices for encounter |
0..* | Reference(Encounter) | Encounters associated with the listed treatments Slice: Unordered, Open by | |||||
| encounter:MopedEncounter |
0..1 | Reference(MOPEDEncounter) | Generelle Informationen zu Aufnahme und Entlassung des Patienten | |||||
| encounter:TransferEncounter |
0..* | Reference(MOPEDTransferEncounter) | Informationen zu Verlegungen innerhalb oder zwischen Krankenanstalten | |||||
| diagnosisRelatedGroup |
0..1 | CodeableConcept | "Abrechnung - Gruppe:" Dieses Datenfeld ist mit der Codenummer der zutreffenden Abrechnungsgruppe zu befüllen. Bei Datensätzen von stationären Krankenhausaufenthalten, die keiner leistungsorientier- ten Diagnosenfallgruppe zugeordnet werden, erfolgt ein Eintrag entsprechend der jeweiligen Aufnahmeart. Binding: http://tbd.at/MOPED-LKFAbrechnungsGruppe (required) | |||||
| item |
0..* | BackboneElement | Adjudication for claim line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
1..1 | positiveInt | Claim item instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | BackboneElement | Adjudication results | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| decision |
0..1 | CodeableConcept | Result of the adjudication Binding: ClaimAdjudicationDecisionsCodes (example) | |||||
| reason |
0..* | CodeableConcept | Reason for result of the adjudication Binding: ClaimAdjudicationDecisionReasonCodes (example) | |||||
| preAuthRef |
0..1 | string | Preauthorization reference | |||||
| preAuthPeriod |
0..1 | Period | Preauthorization reference effective period | |||||
| adjudication |
0..* | BackboneElement | Adjudication details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | |||||
| reason |
0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example): The adjudication reason codes. | |||||
| amount |
0..1 | Money | Monetary amount | |||||
| quantity |
0..1 | Quantity | Non-monetary value | |||||
| detail |
0..* | BackboneElement | Adjudication for claim details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| detailSequence |
1..1 | positiveInt | Claim detail instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Detail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Detail level adjudication details | |||||
| subDetail |
0..* | BackboneElement | Adjudication for claim sub-details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| subDetailSequence |
1..1 | positiveInt | Claim sub-detail instance identifier | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Subdetail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details | |||||
| addItem |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| itemSequence |
0..* | positiveInt | Item sequence number | |||||
| detailSequence |
0..* | positiveInt | Detail sequence number | |||||
| subdetailSequence |
0..* | positiveInt | Subdetail sequence number | |||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| provider |
0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| request |
0..* | Reference(DeviceRequest | MedicationRequest | NutritionOrder | ServiceRequest | SupplyRequest | VisionPrescription) | Request or Referral for Service | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| programCode |
0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes. | |||||
| serviced[x] |
0..1 | Date or dates of service or product delivery | ||||||
| servicedDate |
date | |||||||
| servicedPeriod |
Period | |||||||
| location[x] |
0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc. | ||||||
| locationCodeableConcept |
CodeableConcept | |||||||
| locationAddress |
Address | |||||||
| locationReference |
Reference(Location) | |||||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| bodySite |
0..* | BackboneElement | Anatomical location | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| site |
1..* | CodeableReference(BodyStructure) | Location Binding: OralSiteCodes (example) | |||||
| subSite |
0..* | CodeableConcept | Sub-location Binding: SurfaceCodes (example) | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items adjudication | |||||
| detail |
0..* | BackboneElement | Insurer added line details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items detail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items detail adjudication | |||||
| subDetail |
0..* | BackboneElement | Insurer added line items | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| traceNumber |
0..* | Identifier | Number for tracking | |||||
| revenue |
0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example): Codes for the revenue or cost centers supplying the service and/or products. | |||||
| productOrService |
0..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes. | |||||
| productOrServiceEnd |
0..1 | CodeableConcept | End of a range of codes Binding: USCLSCodes (example) | |||||
| modifier |
0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. | |||||
| quantity |
0..1 | SimpleQuantity | Count of products or services | |||||
| unitPrice |
0..1 | Money | Fee, charge or cost per item | |||||
| factor |
0..1 | decimal | Price scaling factor | |||||
| tax |
0..1 | Money | Total tax | |||||
| net |
0..1 | Money | Total item cost | |||||
| noteNumber |
0..* | positiveInt | Applicable note numbers | |||||
| reviewOutcome |
0..1 | See reviewOutcome (ClaimResponse) | Added items subdetail level adjudication results | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Added items subdetail adjudication | |||||
| adjudication |
0..* | See adjudication (ClaimResponse) | Header-level adjudication | |||||
| total |
Σ | 0..* | BackboneElement | Adjudication totals | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| category |
Σ | 1..1 | CodeableConcept | Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes. | ||||
| amount |
Σ | 1..1 | Money | Financial total for the category | ||||
| payment |
0..1 | BackboneElement | Payment Details | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| type |
1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment. | |||||
| adjustment |
0..1 | Money | Payment adjustment for non-claim issues | |||||
| adjustmentReason |
0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes. | |||||
| date |
0..1 | date | Expected date of payment | |||||
| amount |
1..1 | Money | Payable amount after adjustment | |||||
| identifier |
0..1 | Identifier | Business identifier for the payment | |||||
| fundsReserve |
0..1 | CodeableConcept | Funds reserved status Binding: FundsReservationCodes (example): For whom funds are to be reserved: (Patient, Provider, None). | |||||
| formCode |
0..1 | CodeableConcept | Printed form identifier Binding: FormCodes (example): The forms codes. | |||||
| form |
0..1 | Attachment | Printed reference or actual form | |||||
| processNote |
0..* | BackboneElement | Note concerning adjudication | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| number |
0..1 | positiveInt | Note instance identifier | |||||
| type |
0..1 | CodeableConcept | Note purpose Binding: NoteType (extensible): The presentation types of notes. | |||||
| text |
1..1 | string | Note explanatory text | |||||
| language |
0..1 | CodeableConcept | Language of the text Binding: AllLanguages (required): IETF language tag for a human language
| |||||
| communicationRequest |
0..* | Reference(CommunicationRequest) | Request for additional information | |||||
| insurance |
0..* | BackboneElement | Patient insurance information | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| sequence |
1..1 | positiveInt | Insurance instance identifier | |||||
| focal |
1..1 | boolean | Coverage to be used for adjudication | |||||
| coverage |
1..1 | Reference(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 | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI |
| ClaimResponse.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| ClaimResponse.status | required | FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|5.0.0from the FHIR Standard | |
| ClaimResponse.type | extensible | ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-typefrom the FHIR Standard | |
| ClaimResponse.subType | example | ExampleClaimSubTypeCodeshttp://hl7.org/fhir/ValueSet/claim-subtypefrom the FHIR Standard | |
| ClaimResponse.use | required | Usehttp://hl7.org/fhir/ValueSet/claim-use|5.0.0from the FHIR Standard | |
| ClaimResponse.outcome | required | ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/claim-outcome|5.0.0from the FHIR Standard | |
| ClaimResponse.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decisionfrom the FHIR Standard | |
| ClaimResponse.event.type | example | DatesTypeCodeshttp://hl7.org/fhir/ValueSet/datestypefrom the FHIR Standard | |
| ClaimResponse.payeeType | example | ClaimPayeeTypeCodeshttp://hl7.org/fhir/ValueSet/payeetypefrom the FHIR Standard | |
| ClaimResponse.diagnosisRelatedGroup | required | http://tbd.at/MOPED-LKFAbrechnungsGruppehttp://tbd.at/MOPED-LKFAbrechnungsGruppe | |
| ClaimResponse.item.reviewOutcome.decision | example | ClaimAdjudicationDecisionsCodeshttp://hl7.org/fhir/ValueSet/claim-decisionfrom the FHIR Standard | |
| ClaimResponse.item.reviewOutcome.reason | example | ClaimAdjudicationDecisionReasonCodeshttp://hl7.org/fhir/ValueSet/claim-decision-reasonfrom the FHIR Standard | |
| ClaimResponse.item.adjudication.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.item.adjudication.reason | example | AdjudicationReasonCodeshttp://hl7.org/fhir/ValueSet/adjudication-reasonfrom the FHIR Standard | |
| ClaimResponse.addItem.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodeshttp://hl7.org/fhir/ValueSet/ex-program-codefrom the FHIR Standard | |
| ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodeshttp://hl7.org/fhir/ValueSet/service-placefrom the FHIR Standard | |
| ClaimResponse.addItem.bodySite.site | example | OralSiteCodeshttp://hl7.org/fhir/ValueSet/toothfrom the FHIR Standard | |
| ClaimResponse.addItem.bodySite.subSite | example | SurfaceCodeshttp://hl7.org/fhir/ValueSet/surfacefrom the FHIR Standard | |
| ClaimResponse.addItem.detail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.revenue | example | ExampleRevenueCenterCodeshttp://hl7.org/fhir/ValueSet/ex-revenue-centerfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.productOrServiceEnd | example | USCLSCodeshttp://hl7.org/fhir/ValueSet/service-usclsfrom the FHIR Standard | |
| ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodeshttp://hl7.org/fhir/ValueSet/claim-modifiersfrom the FHIR Standard | |
| ClaimResponse.total.category | example | AdjudicationValueCodeshttp://hl7.org/fhir/ValueSet/adjudicationfrom the FHIR Standard | |
| ClaimResponse.payment.type | example | ExamplePaymentTypeCodeshttp://hl7.org/fhir/ValueSet/ex-paymenttypefrom the FHIR Standard | |
| ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodeshttp://hl7.org/fhir/ValueSet/payment-adjustment-reasonfrom the FHIR Standard | |
| ClaimResponse.fundsReserve | example | FundsReservationCodeshttp://hl7.org/fhir/ValueSet/fundsreservefrom the FHIR Standard | |
| ClaimResponse.formCode | example | FormCodeshttp://hl7.org/fhir/ValueSet/formsfrom the FHIR Standard | |
| ClaimResponse.processNote.type | extensible | NoteTypehttp://hl7.org/fhir/ValueSet/note-typefrom the FHIR Standard | |
| ClaimResponse.processNote.language | required | AllLanguageshttp://hl7.org/fhir/ValueSet/all-languages|5.0.0from the FHIR Standard | |
| ClaimResponse.error.code | example | AdjudicationErrorCodeshttp://hl7.org/fhir/ValueSet/adjudication-errorfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | ClaimResponse | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | ClaimResponse | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | ClaimResponse | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | ClaimResponse | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from ClaimResponse
Summary
Structures
This structure refers to these other structures:
Extensions
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Slices
This structure defines the following Slices:
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