Finance and Insurance Service (FAIS)
1.0.0 - trial-use International flag

This page is part of the IHE ITI Finance and Insurance Services (v1.0.0: Publication) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: FAISClaimResponse - Detailed Descriptions

Active as of 2024-11-13

Definitions for the IHE.FAIS.ClaimResponse resource profile.

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
2. ClaimResponse.implicitRules
Control0..0
4. ClaimResponse.modifierExtension
Control0..0
6. ClaimResponse.request
Control1..?
TypeReference(FAIS Claim Profile)

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
Definition

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

ShortResponse to a claim predetermination or preauthorization
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.implicitRules
Definition

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.

ShortA set of rules under which this content was created
Comments

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 it's narrative along with other profiles, value sets, etc.

Control0..01
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. ClaimResponse.modifierExtension
Definition

An Extension


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 manageable, 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).

ShortExtensionExtensions that cannot be ignored
Comments

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.

Control0..0*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

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.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
6. ClaimResponse.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

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

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because 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
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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'.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.type
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ClaimResponse.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Claim, preauthorization, predetermination.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.patient
Definition

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.

ShortThe recipient of the products and services
Control1..1
TypeReference(Patient)
Is Modifierfalse
Summarytrue
Requirements

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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. ClaimResponse.created
Definition

The date this resource was created.

ShortResponse creation date
Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortParty responsible for reimbursement
Control1..1
TypeReference(Organization)
Is Modifierfalse
Summarytrue
Requirements

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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. ClaimResponse.request
Definition

Original request resource reference.

ShortId of resource triggering adjudication
Control10..1
TypeReference(FAIS Claim Profile, Claim)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Shortqueued | complete | error | partial
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodeshttp://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

The result of the claim processing.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. ClaimResponse
Definition

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

ShortResponse to a claim predetermination or preauthorization
Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesRemittance Advice
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. ClaimResponse.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. ClaimResponse.meta
Definition

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.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. ClaimResponse.implicitRules
Definition

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.

ShortA set of rules under which this content was created
Comments

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 it's narrative along with other profiles, value sets, etc.

Control0..0
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. ClaimResponse.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

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).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. ClaimResponse.text
Definition

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.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have 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.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. ClaimResponse.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

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.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. ClaimResponse.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. ClaimResponse.modifierExtension
Definition

An Extension

ShortExtension
Control0..0
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. ClaimResponse.identifier
Definition

A unique identifier assigned to this claim response.

ShortBusiness Identifier for a claim response
NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Is Modifierfalse
Summaryfalse
Requirements

Allows claim responses to be distinguished and referenced.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. ClaimResponse.status
Definition

The status of the resource instance.

Shortactive | cancelled | draft | entered-in-error
Comments

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

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodes
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because 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
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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'.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. ClaimResponse.type
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. ClaimResponse.subType
Definition

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

ShortMore granular claim type
Comments

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

Control0..1
BindingFor example codes, see ExampleClaimSubTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-subtype)

A more granular claim typecode.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. ClaimResponse.use
Definition

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Shortclaim | preauthorization | predetermination
Control1..1
BindingThe codes SHALL be taken from Use
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

Claim, preauthorization, predetermination.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. ClaimResponse.patient
Definition

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.

ShortThe recipient of the products and services
Control1..1
TypeReference(Patient)
Is Modifierfalse
Summarytrue
Requirements

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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. ClaimResponse.created
Definition

The date this resource was created.

ShortResponse creation date
Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

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

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. ClaimResponse.insurer
Definition

The party responsible for authorization, adjudication and reimbursement.

ShortParty responsible for reimbursement
Control1..1
TypeReference(Organization)
Is Modifierfalse
Summarytrue
Requirements

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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. ClaimResponse.requestor
Definition

The provider which is responsible for the claim, predetermination or preauthorization.

ShortParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control0..1
TypeReference(Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. ClaimResponse.request
Definition

Original request resource reference.

ShortId of resource triggering adjudication
Control1..1
TypeReference(FAIS Claim Profile)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. ClaimResponse.outcome
Definition

The outcome of the claim, predetermination, or preauthorization processing.

Shortqueued | complete | error | partial
Comments

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

Control1..1
BindingThe codes SHALL be taken from ClaimProcessingCodes
(required to http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1)

The result of the claim processing.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

To advise the requestor of an overall processing outcome.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. ClaimResponse.disposition
Definition

A human readable description of the status of the adjudication.

ShortDisposition Message
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provided for user display.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. ClaimResponse.preAuthRef
Definition

Reference from the Insurer which is used in later communications which refers to this adjudication.

ShortPreauthorization reference
Comments

This value is only present on preauthorization adjudications.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

On subsequent claims, the insurer may require the provider to quote this value.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. ClaimResponse.preAuthPeriod
Definition

The time frame during which this authorization is effective.

ShortPreauthorization reference effective period
Control0..1
TypePeriod
Is Modifierfalse
Summaryfalse
Requirements

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. ClaimResponse.payeeType
Definition

Type of Party to be reimbursed: subscriber, provider, other.

ShortParty to be paid any benefits payable
Control0..1
BindingFor example codes, see Claim Payee Type Codes
(example to http://hl7.org/fhir/ValueSet/payeetype)

A code for the party to be reimbursed.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. ClaimResponse.item
Definition

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.

ShortAdjudication for claim line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

The adjudication for items provided on the claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. ClaimResponse.item.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
52. ClaimResponse.item.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
54. ClaimResponse.item.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
56. ClaimResponse.item.itemSequence
Definition

A number to uniquely reference the claim item entries.

ShortClaim item instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. ClaimResponse.item.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. ClaimResponse.item.adjudication
Definition

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.

ShortAdjudication details
Control1..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. ClaimResponse.item.adjudication.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
64. ClaimResponse.item.adjudication.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. ClaimResponse.item.adjudication.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
68. ClaimResponse.item.adjudication.category
Definition

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.

ShortType of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to enable understanding of the context of the other information in the adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. ClaimResponse.item.adjudication.reason
Definition

A code supporting the understanding of the adjudication result and explaining variance from expected amount.

ShortExplanation of adjudication outcome
Comments

For example may indicate that the funds for this benefit type have been exhausted.

Control0..1
BindingFor example codes, see AdjudicationReasonCodes
(example to http://hl7.org/fhir/ValueSet/adjudication-reason)

The adjudication reason codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To support understanding of variance from adjudication expectations.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. ClaimResponse.item.adjudication.amount
Definition

Monetary amount associated with the category.

ShortMonetary amount
Comments

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

Most adjuciation categories convey a monetary amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. ClaimResponse.item.adjudication.value
Definition

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

ShortNon-monetary value
Comments

For example: eligible percentage or co-payment percentage.

Control0..1
Typedecimal
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Some adjudication categories convey a percentage or a fixed value.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. ClaimResponse.item.detail
Definition

A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

ShortAdjudication for claim details
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

The adjudication for details provided on the claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. ClaimResponse.item.detail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
80. ClaimResponse.item.detail.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. ClaimResponse.item.detail.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
84. ClaimResponse.item.detail.detailSequence
Definition

A number to uniquely reference the claim detail entry.

ShortClaim detail instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. ClaimResponse.item.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. ClaimResponse.item.detail.adjudication
Definition

The adjudication results.

ShortDetail level adjudication details
Control1..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. ClaimResponse.item.detail.subDetail
Definition

A sub-detail adjudication of a simple product or service.

ShortAdjudication for claim sub-details
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

The adjudication for sub-details provided on the claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. ClaimResponse.item.detail.subDetail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
94. ClaimResponse.item.detail.subDetail.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
96. ClaimResponse.item.detail.subDetail.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
98. ClaimResponse.item.detail.subDetail.subDetailSequence
Definition

A number to uniquely reference the claim sub-detail entry.

ShortClaim sub-detail instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. ClaimResponse.item.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. ClaimResponse.item.detail.subDetail.adjudication
Definition

The adjudication results.

ShortSubdetail level adjudication details
Control0..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. ClaimResponse.addItem
Definition

The first-tier service adjudications for payor added product or service lines.

ShortInsurer added line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

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.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. ClaimResponse.addItem.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
108. ClaimResponse.addItem.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
110. ClaimResponse.addItem.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
112. ClaimResponse.addItem.itemSequence
Definition

Claim items which this service line is intended to replace.

ShortItem sequence number
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim items.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. ClaimResponse.addItem.detailSequence
Definition

The sequence number of the details within the claim item which this line is intended to replace.

ShortDetail sequence number
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim details within the claim item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. ClaimResponse.addItem.subdetailSequence
Definition

The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

ShortSubdetail sequence number
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim sub-details within the claim detail.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. ClaimResponse.addItem.provider
Definition

The providers who are authorized for the services rendered to the patient.

ShortAuthorized providers
Control0..*
TypeReference(Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. ClaimResponse.addItem.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortBilling, service, product, or drug code
Comments

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'.

Control1..1
BindingFor example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls)

Allowable service and product codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Necessary to state what was provided or done.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. ClaimResponse.addItem.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

ShortService/Product billing modifiers
Comments

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.

Control0..*
BindingFor example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. ClaimResponse.addItem.programCode
Definition

Identifies the program under which this may be recovered.

ShortProgram the product or service is provided under
Comments

For example: Neonatal program, child dental program or drug users recovery program.

Control0..*
BindingFor example codes, see ExampleProgramReasonCodes
(example to http://hl7.org/fhir/ValueSet/ex-program-code)

Program specific reason codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. ClaimResponse.addItem.serviced[x]
Definition

The date or dates when the service or product was supplied, performed or completed.

ShortDate or dates of service or product delivery
Control0..1
TypeChoice of: date, Period
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. ClaimResponse.addItem.location[x]
Definition

Where the product or service was provided.

ShortPlace of service or where product was supplied
Control0..1
BindingFor example codes, see ExampleServicePlaceCodes
(example to http://hl7.org/fhir/ValueSet/service-place)

Place of service: pharmacy, school, prison, etc.

TypeChoice of: CodeableConcept, Address, Reference(Location)
[x] NoteSeeChoice of Data Typesfor further information about how to use [x]
Is Modifierfalse
Summaryfalse
Requirements

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. ClaimResponse.addItem.quantity
Definition

The number of repetitions of a service or product.

ShortCount of products or services
Control0..1
TypeQuantity(SimpleQuantity)
Is Modifierfalse
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
132. ClaimResponse.addItem.unitPrice
Definition

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.

ShortFee, charge or cost per item
Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

The amount charged to the patient by the provider for a single unit.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
134. ClaimResponse.addItem.factor
Definition

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.

ShortPrice scaling factor
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Control0..1
Typedecimal
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
136. ClaimResponse.addItem.net
Definition

The quantity times the unit price for an additional service or product or charge.

ShortTotal item cost
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. ClaimResponse.addItem.bodySite
Definition

Physical service site on the patient (limb, tooth, etc.).

ShortAnatomical location
Comments

For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

Control0..1
BindingFor example codes, see OralSiteCodes
(example to http://hl7.org/fhir/ValueSet/tooth)

The code for the teeth, quadrant, sextant and arch.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows insurer to validate specific procedures.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. ClaimResponse.addItem.subSite
Definition

A region or surface of the bodySite, e.g. limb region or tooth surface(s).

ShortAnatomical sub-location
Control0..*
BindingFor example codes, see SurfaceCodes
(example to http://hl7.org/fhir/ValueSet/surface)

The code for the tooth surface and surface combinations.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows insurer to validate specific procedures.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. ClaimResponse.addItem.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
144. ClaimResponse.addItem.adjudication
Definition

The adjudication results.

ShortAdded items adjudication
Control1..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. ClaimResponse.addItem.detail
Definition

The second-tier service adjudications for payor added services.

ShortInsurer added line details
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. ClaimResponse.addItem.detail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
150. ClaimResponse.addItem.detail.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
152. ClaimResponse.addItem.detail.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
154. ClaimResponse.addItem.detail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortBilling, service, product, or drug code
Comments

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'.

Control1..1
BindingFor example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls)

Allowable service and product codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Necessary to state what was provided or done.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
156. ClaimResponse.addItem.detail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

ShortService/Product billing modifiers
Comments

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.

Control0..*
BindingFor example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. ClaimResponse.addItem.detail.quantity
Definition

The number of repetitions of a service or product.

ShortCount of products or services
Control0..1
TypeQuantity(SimpleQuantity)
Is Modifierfalse
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
160. ClaimResponse.addItem.detail.unitPrice
Definition

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.

ShortFee, charge or cost per item
Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

The amount charged to the patient by the provider for a single unit.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
162. ClaimResponse.addItem.detail.factor
Definition

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.

ShortPrice scaling factor
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Control0..1
Typedecimal
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
164. ClaimResponse.addItem.detail.net
Definition

The quantity times the unit price for an additional service or product or charge.

ShortTotal item cost
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
166. ClaimResponse.addItem.detail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
168. ClaimResponse.addItem.detail.adjudication
Definition

The adjudication results.

ShortAdded items detail adjudication
Control1..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
170. ClaimResponse.addItem.detail.subDetail
Definition

The third-tier service adjudications for payor added services.

ShortInsurer added line items
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
172. ClaimResponse.addItem.detail.subDetail.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
174. ClaimResponse.addItem.detail.subDetail.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
176. ClaimResponse.addItem.detail.subDetail.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
178. ClaimResponse.addItem.detail.subDetail.productOrService
Definition

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortBilling, service, product, or drug code
Comments

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'.

Control1..1
BindingFor example codes, see USCLSCodes
(example to http://hl7.org/fhir/ValueSet/service-uscls)

Allowable service and product codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Necessary to state what was provided or done.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
180. ClaimResponse.addItem.detail.subDetail.modifier
Definition

Item typification or modifiers codes to convey additional context for the product or service.

ShortService/Product billing modifiers
Comments

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.

Control0..*
BindingFor example codes, see ModifierTypeCodes
(example to http://hl7.org/fhir/ValueSet/claim-modifiers)

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To support inclusion of the item for adjudication or to charge an elevated fee.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
182. ClaimResponse.addItem.detail.subDetail.quantity
Definition

The number of repetitions of a service or product.

ShortCount of products or services
Control0..1
TypeQuantity(SimpleQuantity)
Is Modifierfalse
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. ClaimResponse.addItem.detail.subDetail.unitPrice
Definition

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.

ShortFee, charge or cost per item
Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

The amount charged to the patient by the provider for a single unit.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
186. ClaimResponse.addItem.detail.subDetail.factor
Definition

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.

ShortPrice scaling factor
Comments

To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

Control0..1
Typedecimal
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
188. ClaimResponse.addItem.detail.subDetail.net
Definition

The quantity times the unit price for an additional service or product or charge.

ShortTotal item cost
Comments

For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

Provides the total amount claimed for the group (if a grouper) or the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
190. ClaimResponse.addItem.detail.subDetail.noteNumber
Definition

The numbers associated with notes below which apply to the adjudication of this item.

ShortApplicable note numbers
Control0..*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
192. ClaimResponse.addItem.detail.subDetail.adjudication
Definition

The adjudication results.

ShortAdded items detail adjudication
Control1..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
194. ClaimResponse.adjudication
Definition

The adjudication results which are presented at the header level rather than at the line-item or add-item levels.

ShortHeader-level adjudication
Control0..*
TypeSeettp://hl7.org/fhir/StructureDefinition/ClaimResponse#ClaimResponse.item.adjudication
Is Modifierfalse
Summaryfalse
Requirements

Some insurers will receive line-items but provide the adjudication only at a summary or header-level.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
196. ClaimResponse.total
Definition

Categorized monetary totals for the adjudication.

ShortAdjudication totals
Comments

Totals for amounts submitted, co-pays, benefits payable etc.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Requirements

To provide the requestor with financial totals by category for the adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
198. ClaimResponse.total.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
200. ClaimResponse.total.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
202. ClaimResponse.total.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
204. ClaimResponse.total.category
Definition

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.

ShortType of adjudication information
Comments

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Control1..1
BindingFor example codes, see AdjudicationValueCodes
(example to http://hl7.org/fhir/ValueSet/adjudication)

The adjudication codes.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Needed to convey the type of total provided.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
206. ClaimResponse.total.amount
Definition

Monetary total amount associated with the category.

ShortFinancial total for the category
Control1..1
TypeMoney
Is Modifierfalse
Summarytrue
Requirements

Needed to convey the total monetary amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
208. ClaimResponse.payment
Definition

Payment details for the adjudication of the claim.

ShortPayment Details
Control0..1
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Needed to convey references to the financial instrument that has been used if payment has been made.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
210. ClaimResponse.payment.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
212. ClaimResponse.payment.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
214. ClaimResponse.payment.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
216. ClaimResponse.payment.type
Definition

Whether this represents partial or complete payment of the benefits payable.

ShortPartial or complete payment
Control1..1
BindingFor example codes, see ExamplePaymentTypeCodes
(example to http://hl7.org/fhir/ValueSet/ex-paymenttype)

The type (partial, complete) of the payment.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

To advise the requestor when the insurer believes all payments to have been completed.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
218. ClaimResponse.payment.adjustment
Definition

Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication.

ShortPayment adjustment for non-claim issues
Comments

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.

Control0..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

To advise the requestor of adjustments applied to the payment.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
220. ClaimResponse.payment.adjustmentReason
Definition

Reason for the payment adjustment.

ShortExplanation for the adjustment
Control0..1
BindingFor example codes, see PaymentAdjustmentReasonCodes
(example to http://hl7.org/fhir/ValueSet/payment-adjustment-reason)

Payment Adjustment reason codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to clarify the monetary adjustment.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
222. ClaimResponse.payment.date
Definition

Estimated date the payment will be issued or the actual issue date of payment.

ShortExpected date of payment
Control0..1
Typedate
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

To advise the payee when payment can be expected.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
224. ClaimResponse.payment.amount
Definition

Benefits payable less any payment adjustment.

ShortPayable amount after adjustment
Control1..1
TypeMoney
Is Modifierfalse
Summaryfalse
Requirements

Needed to provide the actual payment amount.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
226. ClaimResponse.payment.identifier
Definition

Issuer's unique identifier for the payment instrument.

ShortBusiness identifier for the payment
Comments

For example: EFT number or check number.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Is Modifierfalse
Summaryfalse
Requirements

Enable the receiver to reconcile when payment received.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
228. ClaimResponse.fundsReserve
Definition

A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom.

ShortFunds reserved status
Comments

Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none.

Control0..1
BindingFor example codes, see Funds Reservation Codes
(example to http://hl7.org/fhir/ValueSet/fundsreserve)

For whom funds are to be reserved: (Patient, Provider, None).

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
230. ClaimResponse.formCode
Definition

A code for the form to be used for printing the content.

ShortPrinted form identifier
Comments

May be needed to identify specific jurisdictional forms.

Control0..1
BindingFor example codes, see Form Codes
(example to http://hl7.org/fhir/ValueSet/forms)

The forms codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Needed to specify the specific form used for producing output for this response.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
232. ClaimResponse.form
Definition

The actual form, by reference or inclusion, for printing the content or an EOB.

ShortPrinted reference or actual form
Comments

Needed to permit insurers to include the actual form.

Control0..1
TypeAttachment
Is Modifierfalse
Summaryfalse
Requirements

Needed to include the specific form used for producing output for this response.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
234. ClaimResponse.processNote
Definition

A note that describes or explains adjudication results in a human readable form.

ShortNote concerning adjudication
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Provides the insurer specific textual explanations associated with the processing.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
236. ClaimResponse.processNote.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
238. ClaimResponse.processNote.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
240. ClaimResponse.processNote.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
242. ClaimResponse.processNote.number
Definition

A number to uniquely identify a note entry.

ShortNote instance identifier
Control0..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Necessary to provide a mechanism to link from adjudications.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
244. ClaimResponse.processNote.type
Definition

The business purpose of the note text.

Shortdisplay | print | printoper
Control0..1
BindingThe codes SHALL be taken from NoteType
(required to http://hl7.org/fhir/ValueSet/note-type|4.0.1)

The presentation types of notes.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

To convey the expectation for when the text is used.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
246. ClaimResponse.processNote.text
Definition

The explanation or description associated with the processing.

ShortNote explanatory text
Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Required to provide human readable explanation.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
248. ClaimResponse.processNote.language
Definition

A code to define the language used in the text of the note.

ShortLanguage of the text
Comments

Only required if the language is different from the resource language.

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Note text may vary from the resource defined language.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
250. ClaimResponse.communicationRequest
Definition

Request for additional supporting or authorizing information.

ShortRequest for additional information
Comments

For example: professional reports, documents, images, clinical resources, or accident reports.

Control0..*
TypeReference(CommunicationRequest)
Is Modifierfalse
Summaryfalse
Requirements

Need to communicate insurer request for additional information required to support the adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
252. ClaimResponse.insurance
Definition

Financial instruments for reimbursement for the health care products and services specified on the claim.

ShortPatient insurance information
Comments

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.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

At least one insurer is required for a claim to be a claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
254. ClaimResponse.insurance.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
256. ClaimResponse.insurance.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
258. ClaimResponse.insurance.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
260. ClaimResponse.insurance.sequence
Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

ShortInsurance instance identifier
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

To maintain order of the coverages.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
262. ClaimResponse.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

ShortCoverage to be used for adjudication
Comments

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.

Control1..1
Typeboolean
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
264. ClaimResponse.insurance.coverage
Definition

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.

ShortInsurance information
Control1..1
TypeReference(Coverage)
Is Modifierfalse
Summaryfalse
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
266. ClaimResponse.insurance.businessArrangement
Definition

A business agreement number established between the provider and the insurer for special business processing purposes.

ShortAdditional provider contract number
Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
268. ClaimResponse.insurance.claimResponse
Definition

The result of the adjudication of the line items for the Coverage specified in this insurance.

ShortAdjudication results
Comments

Must not be specified when 'focal=true' for this insurance.

Control0..1
TypeReference(ClaimResponse)
Is Modifierfalse
Summaryfalse
Requirements

An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
270. ClaimResponse.error
Definition

Errors encountered during the processing of the adjudication.

ShortProcessing errors
Comments

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Need to communicate processing issues to the requestor.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
272. ClaimResponse.error.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
274. ClaimResponse.error.extension
Definition

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 manageable, 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.

ShortAdditional content defined by implementations
Comments

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.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
276. ClaimResponse.error.modifierExtension
Definition

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 manageable, 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).

ShortExtensions that cannot be ignored even if unrecognized
Comments

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.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

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.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
278. ClaimResponse.error.itemSequence
Definition

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.

ShortItem sequence number
Control0..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim items.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
280. ClaimResponse.error.detailSequence
Definition

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.

ShortDetail sequence number
Control0..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim details within the claim item.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
282. ClaimResponse.error.subDetailSequence
Definition

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.

ShortSubdetail sequence number
Control0..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Provides references to the claim sub-details within the claim detail.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
284. ClaimResponse.error.code
Definition

An error code, from a specified code system, which details why the claim could not be adjudicated.

ShortError code detailing processing issues
Control1..1
BindingFor example codes, see Adjudication Error Codes
(example to http://hl7.org/fhir/ValueSet/adjudication-error)

The adjudication error codes.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Required to convey processing errors.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))