ClaimResponse
This resource provides the adjudication details from the processing of a Claim resource.
Columns
Header row
# |
path |
type |
required |
description |
0 |
resourceType |
string |
* |
Resource type identifier. Must be string "ClaimResponse" |
1 |
|
integer |
* |
Number of subrows |
2 |
id |
string |
* |
Logical id of this artifact |
3 |
status |
code |
|
active | cancelled | draft | entered-in-error |
|
type |
CodeableConcept |
|
More granular claim type |
|
type.coding |
Coding |
|
Code defined by a terminology system |
4 |
type.coding.system |
uri |
|
Identity of the terminology system |
5 |
type.coding.version |
string |
|
Version of the system - if relevant |
6 |
type.coding.code |
code |
|
Symbol in syntax defined by the system |
7 |
type.coding.display |
string |
|
Representation defined by the system |
8 |
type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
9 |
type.text |
string |
|
Plain text representation of the concept |
|
subType |
CodeableConcept |
|
More granular claim type |
|
subType.coding |
Coding |
|
Code defined by a terminology system |
10 |
subType.coding.system |
uri |
|
Identity of the terminology system |
11 |
subType.coding.version |
string |
|
Version of the system - if relevant |
12 |
subType.coding.code |
code |
|
Symbol in syntax defined by the system |
13 |
subType.coding.display |
string |
|
Representation defined by the system |
14 |
subType.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
15 |
subType.text |
string |
|
Plain text representation of the concept |
16 |
use |
code |
|
claim | preauthorization | predetermination |
|
patient |
Reference |
|
The recipient of the products and services |
17 |
patient.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
18 |
patient.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
patient.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
19 |
patient.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
patient.identifier.type |
CodeableConcept |
|
Description of identifier |
|
patient.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
20 |
patient.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
21 |
patient.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
22 |
patient.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
23 |
patient.identifier.type.coding.display |
string |
|
Representation defined by the system |
24 |
patient.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
25 |
patient.identifier.type.text |
string |
|
Plain text representation of the concept |
26 |
patient.identifier.system |
uri |
|
The namespace for the identifier value |
27 |
patient.identifier.value |
string |
|
The value that is unique |
|
patient.identifier.period |
Period |
|
Time period when id is/was valid for use |
28 |
patient.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
29 |
patient.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
30 |
patient.display |
string |
|
Text alternative for the resource |
31 |
created |
dateTime |
|
Response creation date |
|
insurer |
Reference |
|
Party responsible for reimbursement |
32 |
insurer.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
33 |
insurer.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
insurer.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
34 |
insurer.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
insurer.identifier.type |
CodeableConcept |
|
Description of identifier |
|
insurer.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
35 |
insurer.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
36 |
insurer.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
37 |
insurer.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
38 |
insurer.identifier.type.coding.display |
string |
|
Representation defined by the system |
39 |
insurer.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
40 |
insurer.identifier.type.text |
string |
|
Plain text representation of the concept |
41 |
insurer.identifier.system |
uri |
|
The namespace for the identifier value |
42 |
insurer.identifier.value |
string |
|
The value that is unique |
|
insurer.identifier.period |
Period |
|
Time period when id is/was valid for use |
43 |
insurer.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
44 |
insurer.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
45 |
insurer.display |
string |
|
Text alternative for the resource |
|
requestor |
Reference |
|
Party responsible for the claim |
46 |
requestor.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
47 |
requestor.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
requestor.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
48 |
requestor.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
requestor.identifier.type |
CodeableConcept |
|
Description of identifier |
|
requestor.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
49 |
requestor.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
50 |
requestor.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
51 |
requestor.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
52 |
requestor.identifier.type.coding.display |
string |
|
Representation defined by the system |
53 |
requestor.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
54 |
requestor.identifier.type.text |
string |
|
Plain text representation of the concept |
55 |
requestor.identifier.system |
uri |
|
The namespace for the identifier value |
56 |
requestor.identifier.value |
string |
|
The value that is unique |
|
requestor.identifier.period |
Period |
|
Time period when id is/was valid for use |
57 |
requestor.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
58 |
requestor.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
59 |
requestor.display |
string |
|
Text alternative for the resource |
|
request |
Reference |
|
Id of resource triggering adjudication |
60 |
request.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
61 |
request.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
request.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
62 |
request.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
request.identifier.type |
CodeableConcept |
|
Description of identifier |
|
request.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
63 |
request.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
64 |
request.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
65 |
request.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
66 |
request.identifier.type.coding.display |
string |
|
Representation defined by the system |
67 |
request.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
68 |
request.identifier.type.text |
string |
|
Plain text representation of the concept |
69 |
request.identifier.system |
uri |
|
The namespace for the identifier value |
70 |
request.identifier.value |
string |
|
The value that is unique |
|
request.identifier.period |
Period |
|
Time period when id is/was valid for use |
71 |
request.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
72 |
request.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
73 |
request.display |
string |
|
Text alternative for the resource |
74 |
outcome |
code |
|
queued | complete | error | partial |
75 |
disposition |
string |
|
Disposition Message |
76 |
preAuthRef |
string |
|
Preauthorization reference |
|
preAuthPeriod |
Period |
|
Preauthorization reference effective period |
77 |
preAuthPeriod.start |
dateTime |
|
Starting time with inclusive boundary |
78 |
preAuthPeriod.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
|
payeeType |
CodeableConcept |
|
Party to be paid any benefits payable |
|
payeeType.coding |
Coding |
|
Code defined by a terminology system |
79 |
payeeType.coding.system |
uri |
|
Identity of the terminology system |
80 |
payeeType.coding.version |
string |
|
Version of the system - if relevant |
81 |
payeeType.coding.code |
code |
|
Symbol in syntax defined by the system |
82 |
payeeType.coding.display |
string |
|
Representation defined by the system |
83 |
payeeType.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
84 |
payeeType.text |
string |
|
Plain text representation of the concept |
|
payment |
|
|
Payment Details |
|
payment.type |
CodeableConcept |
|
Partial or complete payment |
|
payment.type.coding |
Coding |
|
Code defined by a terminology system |
85 |
payment.type.coding.system |
uri |
|
Identity of the terminology system |
86 |
payment.type.coding.version |
string |
|
Version of the system - if relevant |
87 |
payment.type.coding.code |
code |
|
Symbol in syntax defined by the system |
88 |
payment.type.coding.display |
string |
|
Representation defined by the system |
89 |
payment.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
90 |
payment.type.text |
string |
|
Plain text representation of the concept |
|
payment.adjustment |
Money |
|
Payment adjustment for non-claim issues |
91 |
payment.adjustment.value |
decimal |
|
Numerical value (with implicit precision) |
92 |
payment.adjustment.currency |
code |
|
ISO 4217 Currency Code |
|
payment.adjustmentReason |
CodeableConcept |
|
Explanation for the adjustment |
|
payment.adjustmentReason.coding |
Coding |
|
Code defined by a terminology system |
93 |
payment.adjustmentReason.coding.system |
uri |
|
Identity of the terminology system |
94 |
payment.adjustmentReason.coding.version |
string |
|
Version of the system - if relevant |
95 |
payment.adjustmentReason.coding.code |
code |
|
Symbol in syntax defined by the system |
96 |
payment.adjustmentReason.coding.display |
string |
|
Representation defined by the system |
97 |
payment.adjustmentReason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
98 |
payment.adjustmentReason.text |
string |
|
Plain text representation of the concept |
99 |
payment.date |
date |
|
Expected date of payment |
|
payment.amount |
Money |
|
Payable amount after adjustment |
100 |
payment.amount.value |
decimal |
|
Numerical value (with implicit precision) |
101 |
payment.amount.currency |
code |
|
ISO 4217 Currency Code |
|
payment.identifier |
Identifier |
|
Business identifier for the payment |
102 |
payment.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
payment.identifier.type |
CodeableConcept |
|
Description of identifier |
|
payment.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
103 |
payment.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
104 |
payment.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
105 |
payment.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
106 |
payment.identifier.type.coding.display |
string |
|
Representation defined by the system |
107 |
payment.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
108 |
payment.identifier.type.text |
string |
|
Plain text representation of the concept |
109 |
payment.identifier.system |
uri |
|
The namespace for the identifier value |
110 |
payment.identifier.value |
string |
|
The value that is unique |
|
payment.identifier.period |
Period |
|
Time period when id is/was valid for use |
111 |
payment.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
112 |
payment.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
|
fundsReserve |
CodeableConcept |
|
Funds reserved status |
|
fundsReserve.coding |
Coding |
|
Code defined by a terminology system |
113 |
fundsReserve.coding.system |
uri |
|
Identity of the terminology system |
114 |
fundsReserve.coding.version |
string |
|
Version of the system - if relevant |
115 |
fundsReserve.coding.code |
code |
|
Symbol in syntax defined by the system |
116 |
fundsReserve.coding.display |
string |
|
Representation defined by the system |
117 |
fundsReserve.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
118 |
fundsReserve.text |
string |
|
Plain text representation of the concept |
|
formCode |
CodeableConcept |
|
Printed form identifier |
|
formCode.coding |
Coding |
|
Code defined by a terminology system |
119 |
formCode.coding.system |
uri |
|
Identity of the terminology system |
120 |
formCode.coding.version |
string |
|
Version of the system - if relevant |
121 |
formCode.coding.code |
code |
|
Symbol in syntax defined by the system |
122 |
formCode.coding.display |
string |
|
Representation defined by the system |
123 |
formCode.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
124 |
formCode.text |
string |
|
Plain text representation of the concept |
|
form |
Attachment |
|
Printed reference or actual form |
125 |
form.contentType |
code |
|
Mime type of the content, with charset etc. |
126 |
form.language |
code |
|
Human language of the content (BCP-47) |
127 |
form.data |
base64Binary |
|
Data inline, base64ed |
128 |
form.url |
url |
|
Uri where the data can be found |
129 |
form.size |
unsignedInt |
|
Number of bytes of content (if url provided) |
130 |
form.hash |
base64Binary |
|
Hash of the data (sha-1, base64ed) |
131 |
form.title |
string |
|
Label to display in place of the data |
132 |
form.creation |
dateTime |
|
Date attachment was first created |
Row identifier
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "identifier" |
|
identifier |
Identifier |
|
Business Identifier for a claim response |
1 |
identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
identifier.type |
CodeableConcept |
|
Description of identifier |
|
identifier.type.coding |
Coding |
|
Code defined by a terminology system |
2 |
identifier.type.coding.system |
uri |
|
Identity of the terminology system |
3 |
identifier.type.coding.version |
string |
|
Version of the system - if relevant |
4 |
identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
5 |
identifier.type.coding.display |
string |
|
Representation defined by the system |
6 |
identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
7 |
identifier.type.text |
string |
|
Plain text representation of the concept |
8 |
identifier.system |
uri |
|
The namespace for the identifier value |
9 |
identifier.value |
string |
|
The value that is unique |
|
identifier.period |
Period |
|
Time period when id is/was valid for use |
10 |
identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
11 |
identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
Row item
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "item" |
|
item |
|
|
Adjudication for claim line items |
1 |
item.itemSequence |
positiveInt |
|
Claim item instance identifier |
2 |
item.noteNumber |
positiveInt |
|
Applicable note numbers |
|
item.adjudication |
|
|
Adjudication details |
|
item.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
item.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
3 |
item.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
4 |
item.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
5 |
item.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
6 |
item.adjudication.category.coding.display |
string |
|
Representation defined by the system |
7 |
item.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
8 |
item.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
item.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
item.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
9 |
item.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
10 |
item.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
11 |
item.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
12 |
item.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
13 |
item.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
14 |
item.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
item.adjudication.amount |
Money |
|
Monetary amount |
15 |
item.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
16 |
item.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
17 |
item.adjudication.value |
decimal |
|
Non-monetary value |
|
item.detail |
|
|
Adjudication for claim details |
18 |
item.detail.detailSequence |
positiveInt |
|
Claim detail instance identifier |
19 |
item.detail.noteNumber |
positiveInt |
|
Applicable note numbers |
|
item.detail.adjudication |
|
|
Detail level adjudication details |
|
item.detail.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
item.detail.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
20 |
item.detail.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
21 |
item.detail.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
22 |
item.detail.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
23 |
item.detail.adjudication.category.coding.display |
string |
|
Representation defined by the system |
24 |
item.detail.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
25 |
item.detail.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
item.detail.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
item.detail.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
26 |
item.detail.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
27 |
item.detail.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
28 |
item.detail.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
29 |
item.detail.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
30 |
item.detail.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
31 |
item.detail.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
item.detail.adjudication.amount |
Money |
|
Monetary amount |
32 |
item.detail.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
33 |
item.detail.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
34 |
item.detail.adjudication.value |
decimal |
|
Non-monetary value |
|
item.detail.subDetail |
|
|
Adjudication for claim sub-details |
35 |
item.detail.subDetail.subDetailSequence |
positiveInt |
|
Claim sub-detail instance identifier |
36 |
item.detail.subDetail.noteNumber |
positiveInt |
|
Applicable note numbers |
|
item.detail.subDetail.adjudication |
|
|
Subdetail level adjudication details |
|
item.detail.subDetail.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
item.detail.subDetail.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
37 |
item.detail.subDetail.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
38 |
item.detail.subDetail.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
39 |
item.detail.subDetail.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
40 |
item.detail.subDetail.adjudication.category.coding.display |
string |
|
Representation defined by the system |
41 |
item.detail.subDetail.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
42 |
item.detail.subDetail.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
item.detail.subDetail.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
item.detail.subDetail.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
43 |
item.detail.subDetail.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
44 |
item.detail.subDetail.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
45 |
item.detail.subDetail.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
46 |
item.detail.subDetail.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
47 |
item.detail.subDetail.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
48 |
item.detail.subDetail.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
item.detail.subDetail.adjudication.amount |
Money |
|
Monetary amount |
49 |
item.detail.subDetail.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
50 |
item.detail.subDetail.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
51 |
item.detail.subDetail.adjudication.value |
decimal |
|
Non-monetary value |
Row addItem
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "addItem" |
|
addItem |
|
|
Insurer added line items |
1 |
addItem.itemSequence |
positiveInt |
|
Item sequence number |
2 |
addItem.detailSequence |
positiveInt |
|
Detail sequence number |
3 |
addItem.subdetailSequence |
positiveInt |
|
Subdetail sequence number |
|
addItem.provider |
Reference |
|
Authorized providers |
4 |
addItem.provider.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
5 |
addItem.provider.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
addItem.provider.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
6 |
addItem.provider.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
addItem.provider.identifier.type |
CodeableConcept |
|
Description of identifier |
|
addItem.provider.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
7 |
addItem.provider.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
8 |
addItem.provider.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
9 |
addItem.provider.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
10 |
addItem.provider.identifier.type.coding.display |
string |
|
Representation defined by the system |
11 |
addItem.provider.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
12 |
addItem.provider.identifier.type.text |
string |
|
Plain text representation of the concept |
13 |
addItem.provider.identifier.system |
uri |
|
The namespace for the identifier value |
14 |
addItem.provider.identifier.value |
string |
|
The value that is unique |
|
addItem.provider.identifier.period |
Period |
|
Time period when id is/was valid for use |
15 |
addItem.provider.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
16 |
addItem.provider.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
17 |
addItem.provider.display |
string |
|
Text alternative for the resource |
|
addItem.productOrService |
CodeableConcept |
|
Billing, service, product, or drug code |
|
addItem.productOrService.coding |
Coding |
|
Code defined by a terminology system |
18 |
addItem.productOrService.coding.system |
uri |
|
Identity of the terminology system |
19 |
addItem.productOrService.coding.version |
string |
|
Version of the system - if relevant |
20 |
addItem.productOrService.coding.code |
code |
|
Symbol in syntax defined by the system |
21 |
addItem.productOrService.coding.display |
string |
|
Representation defined by the system |
22 |
addItem.productOrService.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
23 |
addItem.productOrService.text |
string |
|
Plain text representation of the concept |
|
addItem.modifier |
CodeableConcept |
|
Service/Product billing modifiers |
|
addItem.modifier.coding |
Coding |
|
Code defined by a terminology system |
24 |
addItem.modifier.coding.system |
uri |
|
Identity of the terminology system |
25 |
addItem.modifier.coding.version |
string |
|
Version of the system - if relevant |
26 |
addItem.modifier.coding.code |
code |
|
Symbol in syntax defined by the system |
27 |
addItem.modifier.coding.display |
string |
|
Representation defined by the system |
28 |
addItem.modifier.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
29 |
addItem.modifier.text |
string |
|
Plain text representation of the concept |
|
addItem.programCode |
CodeableConcept |
|
Program the product or service is provided under |
|
addItem.programCode.coding |
Coding |
|
Code defined by a terminology system |
30 |
addItem.programCode.coding.system |
uri |
|
Identity of the terminology system |
31 |
addItem.programCode.coding.version |
string |
|
Version of the system - if relevant |
32 |
addItem.programCode.coding.code |
code |
|
Symbol in syntax defined by the system |
33 |
addItem.programCode.coding.display |
string |
|
Representation defined by the system |
34 |
addItem.programCode.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
35 |
addItem.programCode.text |
string |
|
Plain text representation of the concept |
|
addItem.serviced[x] |
|
|
Date or dates of service or product delivery |
36 |
addItem.servicedDate |
date |
|
|
|
addItem.servicedPeriod |
Period |
|
|
37 |
addItem.servicedPeriod.start |
dateTime |
|
Starting time with inclusive boundary |
38 |
addItem.servicedPeriod.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
|
addItem.location[x] |
|
|
Place of service or where product was supplied |
|
addItem.locationCodeableConcept |
CodeableConcept |
|
|
|
addItem.locationCodeableConcept.coding |
Coding |
|
Code defined by a terminology system |
39 |
addItem.locationCodeableConcept.coding.system |
uri |
|
Identity of the terminology system |
40 |
addItem.locationCodeableConcept.coding.version |
string |
|
Version of the system - if relevant |
41 |
addItem.locationCodeableConcept.coding.code |
code |
|
Symbol in syntax defined by the system |
42 |
addItem.locationCodeableConcept.coding.display |
string |
|
Representation defined by the system |
43 |
addItem.locationCodeableConcept.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
44 |
addItem.locationCodeableConcept.text |
string |
|
Plain text representation of the concept |
|
addItem.locationAddress |
Address |
|
|
45 |
addItem.locationAddress.use |
code |
|
home | work | temp | old | billing - purpose of this address |
46 |
addItem.locationAddress.type |
code |
|
postal | physical | both |
47 |
addItem.locationAddress.text |
string |
|
Text representation of the address |
48 |
addItem.locationAddress.line |
string |
|
Street name, number, direction & P.O. Box etc. |
49 |
addItem.locationAddress.city |
string |
|
Name of city, town etc. |
50 |
addItem.locationAddress.district |
string |
|
District name (aka county) |
51 |
addItem.locationAddress.state |
string |
|
Sub-unit of country (abbreviations ok) |
52 |
addItem.locationAddress.postalCode |
string |
|
Postal code for area |
53 |
addItem.locationAddress.country |
string |
|
Country (e.g. can be ISO 3166 2 or 3 letter code) |
|
addItem.locationAddress.period |
Period |
|
Time period when address was/is in use |
54 |
addItem.locationAddress.period.start |
dateTime |
|
Starting time with inclusive boundary |
55 |
addItem.locationAddress.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
|
addItem.locationReference |
Reference |
|
|
56 |
addItem.locationReference.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
57 |
addItem.locationReference.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
addItem.locationReference.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
58 |
addItem.locationReference.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
addItem.locationReference.identifier.type |
CodeableConcept |
|
Description of identifier |
|
addItem.locationReference.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
59 |
addItem.locationReference.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
60 |
addItem.locationReference.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
61 |
addItem.locationReference.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
62 |
addItem.locationReference.identifier.type.coding.display |
string |
|
Representation defined by the system |
63 |
addItem.locationReference.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
64 |
addItem.locationReference.identifier.type.text |
string |
|
Plain text representation of the concept |
65 |
addItem.locationReference.identifier.system |
uri |
|
The namespace for the identifier value |
66 |
addItem.locationReference.identifier.value |
string |
|
The value that is unique |
|
addItem.locationReference.identifier.period |
Period |
|
Time period when id is/was valid for use |
67 |
addItem.locationReference.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
68 |
addItem.locationReference.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
69 |
addItem.locationReference.display |
string |
|
Text alternative for the resource |
|
addItem.quantity |
Quantity |
|
Count of products or services |
70 |
addItem.quantity.value |
decimal |
|
Numerical value (with implicit precision) |
71 |
addItem.quantity.unit |
string |
|
Unit representation |
72 |
addItem.quantity.system |
uri |
|
System that defines coded unit form |
73 |
addItem.quantity.code |
code |
|
Coded form of the unit |
|
addItem.unitPrice |
Money |
|
Fee, charge or cost per item |
74 |
addItem.unitPrice.value |
decimal |
|
Numerical value (with implicit precision) |
75 |
addItem.unitPrice.currency |
code |
|
ISO 4217 Currency Code |
76 |
addItem.factor |
decimal |
|
Price scaling factor |
|
addItem.net |
Money |
|
Total item cost |
77 |
addItem.net.value |
decimal |
|
Numerical value (with implicit precision) |
78 |
addItem.net.currency |
code |
|
ISO 4217 Currency Code |
|
addItem.bodySite |
CodeableConcept |
|
Anatomical location |
|
addItem.bodySite.coding |
Coding |
|
Code defined by a terminology system |
79 |
addItem.bodySite.coding.system |
uri |
|
Identity of the terminology system |
80 |
addItem.bodySite.coding.version |
string |
|
Version of the system - if relevant |
81 |
addItem.bodySite.coding.code |
code |
|
Symbol in syntax defined by the system |
82 |
addItem.bodySite.coding.display |
string |
|
Representation defined by the system |
83 |
addItem.bodySite.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
84 |
addItem.bodySite.text |
string |
|
Plain text representation of the concept |
|
addItem.subSite |
CodeableConcept |
|
Anatomical sub-location |
|
addItem.subSite.coding |
Coding |
|
Code defined by a terminology system |
85 |
addItem.subSite.coding.system |
uri |
|
Identity of the terminology system |
86 |
addItem.subSite.coding.version |
string |
|
Version of the system - if relevant |
87 |
addItem.subSite.coding.code |
code |
|
Symbol in syntax defined by the system |
88 |
addItem.subSite.coding.display |
string |
|
Representation defined by the system |
89 |
addItem.subSite.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
90 |
addItem.subSite.text |
string |
|
Plain text representation of the concept |
91 |
addItem.noteNumber |
positiveInt |
|
Applicable note numbers |
|
addItem.adjudication |
|
|
Added items adjudication |
|
addItem.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
addItem.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
92 |
addItem.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
93 |
addItem.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
94 |
addItem.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
95 |
addItem.adjudication.category.coding.display |
string |
|
Representation defined by the system |
96 |
addItem.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
97 |
addItem.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
addItem.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
addItem.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
98 |
addItem.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
99 |
addItem.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
100 |
addItem.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
101 |
addItem.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
102 |
addItem.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
103 |
addItem.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
addItem.adjudication.amount |
Money |
|
Monetary amount |
104 |
addItem.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
105 |
addItem.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
106 |
addItem.adjudication.value |
decimal |
|
Non-monetary value |
|
addItem.detail |
|
|
Insurer added line details |
|
addItem.detail.productOrService |
CodeableConcept |
|
Billing, service, product, or drug code |
|
addItem.detail.productOrService.coding |
Coding |
|
Code defined by a terminology system |
107 |
addItem.detail.productOrService.coding.system |
uri |
|
Identity of the terminology system |
108 |
addItem.detail.productOrService.coding.version |
string |
|
Version of the system - if relevant |
109 |
addItem.detail.productOrService.coding.code |
code |
|
Symbol in syntax defined by the system |
110 |
addItem.detail.productOrService.coding.display |
string |
|
Representation defined by the system |
111 |
addItem.detail.productOrService.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
112 |
addItem.detail.productOrService.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.modifier |
CodeableConcept |
|
Service/Product billing modifiers |
|
addItem.detail.modifier.coding |
Coding |
|
Code defined by a terminology system |
113 |
addItem.detail.modifier.coding.system |
uri |
|
Identity of the terminology system |
114 |
addItem.detail.modifier.coding.version |
string |
|
Version of the system - if relevant |
115 |
addItem.detail.modifier.coding.code |
code |
|
Symbol in syntax defined by the system |
116 |
addItem.detail.modifier.coding.display |
string |
|
Representation defined by the system |
117 |
addItem.detail.modifier.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
118 |
addItem.detail.modifier.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.quantity |
Quantity |
|
Count of products or services |
119 |
addItem.detail.quantity.value |
decimal |
|
Numerical value (with implicit precision) |
120 |
addItem.detail.quantity.unit |
string |
|
Unit representation |
121 |
addItem.detail.quantity.system |
uri |
|
System that defines coded unit form |
122 |
addItem.detail.quantity.code |
code |
|
Coded form of the unit |
|
addItem.detail.unitPrice |
Money |
|
Fee, charge or cost per item |
123 |
addItem.detail.unitPrice.value |
decimal |
|
Numerical value (with implicit precision) |
124 |
addItem.detail.unitPrice.currency |
code |
|
ISO 4217 Currency Code |
125 |
addItem.detail.factor |
decimal |
|
Price scaling factor |
|
addItem.detail.net |
Money |
|
Total item cost |
126 |
addItem.detail.net.value |
decimal |
|
Numerical value (with implicit precision) |
127 |
addItem.detail.net.currency |
code |
|
ISO 4217 Currency Code |
128 |
addItem.detail.noteNumber |
positiveInt |
|
Applicable note numbers |
|
addItem.detail.adjudication |
|
|
Added items detail adjudication |
|
addItem.detail.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
addItem.detail.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
129 |
addItem.detail.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
130 |
addItem.detail.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
131 |
addItem.detail.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
132 |
addItem.detail.adjudication.category.coding.display |
string |
|
Representation defined by the system |
133 |
addItem.detail.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
134 |
addItem.detail.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
addItem.detail.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
135 |
addItem.detail.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
136 |
addItem.detail.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
137 |
addItem.detail.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
138 |
addItem.detail.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
139 |
addItem.detail.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
140 |
addItem.detail.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.adjudication.amount |
Money |
|
Monetary amount |
141 |
addItem.detail.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
142 |
addItem.detail.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
143 |
addItem.detail.adjudication.value |
decimal |
|
Non-monetary value |
|
addItem.detail.subDetail |
|
|
Insurer added line items |
|
addItem.detail.subDetail.productOrService |
CodeableConcept |
|
Billing, service, product, or drug code |
|
addItem.detail.subDetail.productOrService.coding |
Coding |
|
Code defined by a terminology system |
144 |
addItem.detail.subDetail.productOrService.coding.system |
uri |
|
Identity of the terminology system |
145 |
addItem.detail.subDetail.productOrService.coding.version |
string |
|
Version of the system - if relevant |
146 |
addItem.detail.subDetail.productOrService.coding.code |
code |
|
Symbol in syntax defined by the system |
147 |
addItem.detail.subDetail.productOrService.coding.display |
string |
|
Representation defined by the system |
148 |
addItem.detail.subDetail.productOrService.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
149 |
addItem.detail.subDetail.productOrService.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.subDetail.modifier |
CodeableConcept |
|
Service/Product billing modifiers |
|
addItem.detail.subDetail.modifier.coding |
Coding |
|
Code defined by a terminology system |
150 |
addItem.detail.subDetail.modifier.coding.system |
uri |
|
Identity of the terminology system |
151 |
addItem.detail.subDetail.modifier.coding.version |
string |
|
Version of the system - if relevant |
152 |
addItem.detail.subDetail.modifier.coding.code |
code |
|
Symbol in syntax defined by the system |
153 |
addItem.detail.subDetail.modifier.coding.display |
string |
|
Representation defined by the system |
154 |
addItem.detail.subDetail.modifier.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
155 |
addItem.detail.subDetail.modifier.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.subDetail.quantity |
Quantity |
|
Count of products or services |
156 |
addItem.detail.subDetail.quantity.value |
decimal |
|
Numerical value (with implicit precision) |
157 |
addItem.detail.subDetail.quantity.unit |
string |
|
Unit representation |
158 |
addItem.detail.subDetail.quantity.system |
uri |
|
System that defines coded unit form |
159 |
addItem.detail.subDetail.quantity.code |
code |
|
Coded form of the unit |
|
addItem.detail.subDetail.unitPrice |
Money |
|
Fee, charge or cost per item |
160 |
addItem.detail.subDetail.unitPrice.value |
decimal |
|
Numerical value (with implicit precision) |
161 |
addItem.detail.subDetail.unitPrice.currency |
code |
|
ISO 4217 Currency Code |
162 |
addItem.detail.subDetail.factor |
decimal |
|
Price scaling factor |
|
addItem.detail.subDetail.net |
Money |
|
Total item cost |
163 |
addItem.detail.subDetail.net.value |
decimal |
|
Numerical value (with implicit precision) |
164 |
addItem.detail.subDetail.net.currency |
code |
|
ISO 4217 Currency Code |
165 |
addItem.detail.subDetail.noteNumber |
positiveInt |
|
Applicable note numbers |
|
addItem.detail.subDetail.adjudication |
|
|
Added items detail adjudication |
|
addItem.detail.subDetail.adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
addItem.detail.subDetail.adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
166 |
addItem.detail.subDetail.adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
167 |
addItem.detail.subDetail.adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
168 |
addItem.detail.subDetail.adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
169 |
addItem.detail.subDetail.adjudication.category.coding.display |
string |
|
Representation defined by the system |
170 |
addItem.detail.subDetail.adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
171 |
addItem.detail.subDetail.adjudication.category.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.subDetail.adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
addItem.detail.subDetail.adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
172 |
addItem.detail.subDetail.adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
173 |
addItem.detail.subDetail.adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
174 |
addItem.detail.subDetail.adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
175 |
addItem.detail.subDetail.adjudication.reason.coding.display |
string |
|
Representation defined by the system |
176 |
addItem.detail.subDetail.adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
177 |
addItem.detail.subDetail.adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
addItem.detail.subDetail.adjudication.amount |
Money |
|
Monetary amount |
178 |
addItem.detail.subDetail.adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
179 |
addItem.detail.subDetail.adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
180 |
addItem.detail.subDetail.adjudication.value |
decimal |
|
Non-monetary value |
Row adjudication
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "adjudication" |
|
adjudication |
|
|
Header-level adjudication |
|
adjudication.category |
CodeableConcept |
|
Type of adjudication information |
|
adjudication.category.coding |
Coding |
|
Code defined by a terminology system |
1 |
adjudication.category.coding.system |
uri |
|
Identity of the terminology system |
2 |
adjudication.category.coding.version |
string |
|
Version of the system - if relevant |
3 |
adjudication.category.coding.code |
code |
|
Symbol in syntax defined by the system |
4 |
adjudication.category.coding.display |
string |
|
Representation defined by the system |
5 |
adjudication.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
6 |
adjudication.category.text |
string |
|
Plain text representation of the concept |
|
adjudication.reason |
CodeableConcept |
|
Explanation of adjudication outcome |
|
adjudication.reason.coding |
Coding |
|
Code defined by a terminology system |
7 |
adjudication.reason.coding.system |
uri |
|
Identity of the terminology system |
8 |
adjudication.reason.coding.version |
string |
|
Version of the system - if relevant |
9 |
adjudication.reason.coding.code |
code |
|
Symbol in syntax defined by the system |
10 |
adjudication.reason.coding.display |
string |
|
Representation defined by the system |
11 |
adjudication.reason.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
12 |
adjudication.reason.text |
string |
|
Plain text representation of the concept |
|
adjudication.amount |
Money |
|
Monetary amount |
13 |
adjudication.amount.value |
decimal |
|
Numerical value (with implicit precision) |
14 |
adjudication.amount.currency |
code |
|
ISO 4217 Currency Code |
15 |
adjudication.value |
decimal |
|
Non-monetary value |
Row total
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "total" |
|
total |
|
|
Adjudication totals |
|
total.category |
CodeableConcept |
|
Type of adjudication information |
|
total.category.coding |
Coding |
|
Code defined by a terminology system |
1 |
total.category.coding.system |
uri |
|
Identity of the terminology system |
2 |
total.category.coding.version |
string |
|
Version of the system - if relevant |
3 |
total.category.coding.code |
code |
|
Symbol in syntax defined by the system |
4 |
total.category.coding.display |
string |
|
Representation defined by the system |
5 |
total.category.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
6 |
total.category.text |
string |
|
Plain text representation of the concept |
|
total.amount |
Money |
|
Financial total for the category |
7 |
total.amount.value |
decimal |
|
Numerical value (with implicit precision) |
8 |
total.amount.currency |
code |
|
ISO 4217 Currency Code |
Row processNote
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "processNote" |
|
processNote |
|
|
Note concerning adjudication |
1 |
processNote.number |
positiveInt |
|
Note instance identifier |
2 |
processNote.type |
code |
|
display | print | printoper |
3 |
processNote.text |
string |
|
Note explanatory text |
|
processNote.language |
CodeableConcept |
|
Language of the text |
|
processNote.language.coding |
Coding |
|
Code defined by a terminology system |
4 |
processNote.language.coding.system |
uri |
|
Identity of the terminology system |
5 |
processNote.language.coding.version |
string |
|
Version of the system - if relevant |
6 |
processNote.language.coding.code |
code |
|
Symbol in syntax defined by the system |
7 |
processNote.language.coding.display |
string |
|
Representation defined by the system |
8 |
processNote.language.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
9 |
processNote.language.text |
string |
|
Plain text representation of the concept |
Row communicationRequest
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "communicationRequest" |
|
communicationRequest |
Reference |
|
Request for additional information |
1 |
communicationRequest.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
2 |
communicationRequest.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
communicationRequest.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
3 |
communicationRequest.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
communicationRequest.identifier.type |
CodeableConcept |
|
Description of identifier |
|
communicationRequest.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
4 |
communicationRequest.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
5 |
communicationRequest.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
6 |
communicationRequest.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
7 |
communicationRequest.identifier.type.coding.display |
string |
|
Representation defined by the system |
8 |
communicationRequest.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
9 |
communicationRequest.identifier.type.text |
string |
|
Plain text representation of the concept |
10 |
communicationRequest.identifier.system |
uri |
|
The namespace for the identifier value |
11 |
communicationRequest.identifier.value |
string |
|
The value that is unique |
|
communicationRequest.identifier.period |
Period |
|
Time period when id is/was valid for use |
12 |
communicationRequest.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
13 |
communicationRequest.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
14 |
communicationRequest.display |
string |
|
Text alternative for the resource |
Row insurance
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "insurance" |
|
insurance |
|
|
Patient insurance information |
1 |
insurance.sequence |
positiveInt |
|
Insurance instance identifier |
2 |
insurance.focal |
boolean |
|
Coverage to be used for adjudication |
|
insurance.coverage |
Reference |
|
Insurance information |
3 |
insurance.coverage.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
4 |
insurance.coverage.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
insurance.coverage.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
5 |
insurance.coverage.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
insurance.coverage.identifier.type |
CodeableConcept |
|
Description of identifier |
|
insurance.coverage.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
6 |
insurance.coverage.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
7 |
insurance.coverage.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
8 |
insurance.coverage.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
9 |
insurance.coverage.identifier.type.coding.display |
string |
|
Representation defined by the system |
10 |
insurance.coverage.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
11 |
insurance.coverage.identifier.type.text |
string |
|
Plain text representation of the concept |
12 |
insurance.coverage.identifier.system |
uri |
|
The namespace for the identifier value |
13 |
insurance.coverage.identifier.value |
string |
|
The value that is unique |
|
insurance.coverage.identifier.period |
Period |
|
Time period when id is/was valid for use |
14 |
insurance.coverage.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
15 |
insurance.coverage.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
16 |
insurance.coverage.display |
string |
|
Text alternative for the resource |
17 |
insurance.businessArrangement |
string |
|
Additional provider contract number |
|
insurance.claimResponse |
Reference |
|
Adjudication results |
18 |
insurance.claimResponse.reference |
string |
|
Literal reference, Relative, internal or absolute URL |
19 |
insurance.claimResponse.type |
uri |
|
Type the reference refers to (e.g. "Patient") |
|
insurance.claimResponse.identifier |
Identifier |
|
Logical reference, when literal reference is not known |
20 |
insurance.claimResponse.identifier.use |
code |
|
usual | official | temp | secondary | old (If known) |
|
insurance.claimResponse.identifier.type |
CodeableConcept |
|
Description of identifier |
|
insurance.claimResponse.identifier.type.coding |
Coding |
|
Code defined by a terminology system |
21 |
insurance.claimResponse.identifier.type.coding.system |
uri |
|
Identity of the terminology system |
22 |
insurance.claimResponse.identifier.type.coding.version |
string |
|
Version of the system - if relevant |
23 |
insurance.claimResponse.identifier.type.coding.code |
code |
|
Symbol in syntax defined by the system |
24 |
insurance.claimResponse.identifier.type.coding.display |
string |
|
Representation defined by the system |
25 |
insurance.claimResponse.identifier.type.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
26 |
insurance.claimResponse.identifier.type.text |
string |
|
Plain text representation of the concept |
27 |
insurance.claimResponse.identifier.system |
uri |
|
The namespace for the identifier value |
28 |
insurance.claimResponse.identifier.value |
string |
|
The value that is unique |
|
insurance.claimResponse.identifier.period |
Period |
|
Time period when id is/was valid for use |
29 |
insurance.claimResponse.identifier.period.start |
dateTime |
|
Starting time with inclusive boundary |
30 |
insurance.claimResponse.identifier.period.end |
dateTime |
|
End time with inclusive boundary, if not ongoing |
31 |
insurance.claimResponse.display |
string |
|
Text alternative for the resource |
Row error
# |
path |
type |
required |
description |
0 |
|
string |
* |
Subrow identifier. Must be string "error" |
|
error |
|
|
Processing errors |
1 |
error.itemSequence |
positiveInt |
|
Item sequence number |
2 |
error.detailSequence |
positiveInt |
|
Detail sequence number |
3 |
error.subDetailSequence |
positiveInt |
|
Subdetail sequence number |
|
error.code |
CodeableConcept |
|
Error code detailing processing issues |
|
error.code.coding |
Coding |
|
Code defined by a terminology system |
4 |
error.code.coding.system |
uri |
|
Identity of the terminology system |
5 |
error.code.coding.version |
string |
|
Version of the system - if relevant |
6 |
error.code.coding.code |
code |
|
Symbol in syntax defined by the system |
7 |
error.code.coding.display |
string |
|
Representation defined by the system |
8 |
error.code.coding.userSelected |
boolean |
|
If this coding was chosen directly by the user |
9 |
error.code.text |
string |
|
Plain text representation of the concept |
Examples
Example #1
Input CSV
ClaimResponse,4,"R3501","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Practitioner/1",,,,,,,,,,,,,,"Claim/100156",,,,,,,,,,,,,,"error","Claim could not be processed",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,"http://terminology.hl7.org/CodeSystem/forms-codes",,"2",,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3501",,
processNote,1,"display","Invalid claim","urn:ietf:bcp:47",,"en-CA",,,
communicationRequest,"CommunicationRequest/fm-solicit",,,,,,,,,,,,,
error,3,2,,"http://terminology.hl7.org/CodeSystem/adjudication-error",,"a002",,,
Resulting resource
{
"resourceType": "ClaimResponse",
"id": "R3501",
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3501"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestor": {
"reference": "Practitioner/1"
},
"request": {
"reference": "Claim/100156"
},
"outcome": "error",
"disposition": "Claim could not be processed",
"formCode": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/forms-codes",
"code": "2"
}
]
},
"processNote": [
{
"number": 1,
"type": "display",
"text": "Invalid claim",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
],
"communicationRequest": [
{
"reference": "CommunicationRequest/fm-solicit"
}
],
"error": [
{
"itemSequence": 3,
"detailSequence": 2,
"code": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-error",
"code": "a002"
}
]
}
}
]
}
Example #2
Input CSV
ClaimResponse,10,"R3503","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,"http://happyvalley.com/claim","12346",,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,,,,,,,,,"2014-08-31",100.47,"USD",,,,,,,,"http://www.BenefitsInc.com/fhir/paymentidentifier","201408-2-15507",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3503",,
item,1,,,,"eligible",,,,,,,,,,0,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
item,2,,,,"eligible",,,,,,,,,,105,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
item,3,,,,"eligible",,,,,,,,,,750,"USD",,1,,,,"eligible",,,,,,,,,,750,"USD",,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"1101",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.57,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,100,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"2141","Radiograph, bytewing",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.57,"USD",,,,,,,,,,,,,,,,"eligible",,,,,,,,,,35.57,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,3,2,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"expense",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,350,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,350,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,1340.57,"USD"
total,,,"benefit",,,,1054.47,"USD"
processNote,101,"print","Package codes are not permitted. Codes replaced by Insurer.","urn:ietf:bcp:47",,"en-CA",,,
Resulting resource
{
"resourceType": "ClaimResponse",
"id": "R3503",
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3503"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestor": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happyvalley.com/claim",
"value": "12346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
},
{
"itemSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 105,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 84,
"currency": "USD"
}
}
]
},
{
"itemSequence": 3,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600,
"currency": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 750,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 600,
"currency": "USD"
}
}
]
},
{
"detailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 0,
"currency": "USD"
}
}
]
}
]
}
],
"addItem": [
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 135.57,
"currency": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 72,
"currency": "USD"
}
}
]
},
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2141",
"display": "Radiograph, bytewing"
}
]
},
"net": {
"value": 35.57,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 35.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 28.47,
"currency": "USD"
}
}
]
},
{
"itemSequence": [
3
],
"detailSequence": [
2
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "expense"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 350,
"currency": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 350,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 270,
"currency": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 1340.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 1054.47,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"currency": "USD"
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-15507"
}
},
"processNote": [
{
"number": 101,
"type": "print",
"text": "Package codes are not permitted. Codes replaced by Insurer.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
]
}
Example #3
Input CSV
ClaimResponse,4,"R3500","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,"http://terminology.hl7.org/CodeSystem/ex-claimsubtype",,"emergency",,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","555123",,,,"Organization/1",,,,,,,,,,,,,,"http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402",,,,,,,,,,,,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,,,,,,,,,"2014-08-31",100.47,"USD",,,,,,,,"http://www.BenefitsInc.com/fhir/paymentidentifier","201408-2-1569478",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.BenefitsInc.com/fhir/remittance","R3500",,
item,1,,,,"eligible",,,,,,,,,,135.57,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,135.57,"USD"
total,,,"benefit",,,,90.47,"USD"
Resulting resource
{
"resourceType": "ClaimResponse",
"id": "R3500",
"identifier": [
{
"system": "http://www.BenefitsInc.com/fhir/remittance",
"value": "R3500"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"subType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-claimsubtype",
"code": "emergency"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "555123"
}
},
"requestor": {
"reference": "Organization/1"
},
"request": {
"reference": "http://www.BenefitsInc.com/fhir/oralhealthclaim/15476332402"
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"reason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/adjudication-reason",
"code": "ar002",
"display": "Plan Limit Reached"
}
]
},
"amount": {
"value": 90.47,
"currency": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 135.57,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 90.47,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"date": "2014-08-31",
"amount": {
"value": 100.47,
"currency": "USD"
},
"identifier": {
"system": "http://www.BenefitsInc.com/fhir/paymentidentifier",
"value": "201408-2-1569478"
}
}
}
Example #4
Input CSV
ClaimResponse,7,"UR3503","active","http://terminology.hl7.org/CodeSystem/claim-type",,"oral",,,,,,,,,,"preauthorization","Patient/1",,,,,,,,,,,,,,"2014-08-16",,,,,,,,,,"http://www.jurisdiction.org/insurers","444123",,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,,,,,,"complete","The enclosed services are authorized for your provision within 30 days of this notice.","18SS12345",,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://www.SocialBenefitsInc.com/fhir/ClaimResponse","UR3503",,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"1101",,,,"http://example.org/fhir/modifiers",,"x","None",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250,"USD",,,,,,,,,,,,,101,,,"eligible",,,,,,,,,,250,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
addItem,1,,,,,,,,,,,,,,,,,"http://example.org/fhir/oralservicecodes",,"2101","Radiograph, series (12)",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,800,"USD",,,,,,,,,,,,,,,,"eligible",,,,,,,,,,800,"USD",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,1050,"USD"
total,,,"benefit",,,,1040,"USD"
processNote,101,"print","Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.","urn:ietf:bcp:47",,"en-CA",,,
insurance,1,true,"Coverage/9876B1",,,,,,,,,,,,,,,,,,,,,,,,,,,,
Resulting resource
{
"resourceType": "ClaimResponse",
"id": "UR3503",
"identifier": [
{
"system": "http://www.SocialBenefitsInc.com/fhir/ClaimResponse",
"value": "UR3503"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "oral"
}
]
},
"use": "preauthorization",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"identifier": {
"system": "http://www.jurisdiction.org/insurers",
"value": "444123"
}
},
"requestor": {
"reference": "Organization/1"
},
"outcome": "complete",
"disposition": "The enclosed services are authorized for your provision within 30 days of this notice.",
"preAuthRef": "18SS12345",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"addItem": [
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "1101"
}
]
},
"modifier": [
{
"coding": [
{
"system": "http://example.org/fhir/modifiers",
"code": "x",
"display": "None"
}
]
}
],
"net": {
"value": 250,
"currency": "USD"
},
"noteNumber": [
101
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 250,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 10,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 100
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 240,
"currency": "USD"
}
}
]
},
{
"itemSequence": [
1
],
"productOrService": {
"coding": [
{
"system": "http://example.org/fhir/oralservicecodes",
"code": "2101",
"display": "Radiograph, series (12)"
}
]
},
"net": {
"value": 800,
"currency": "USD"
},
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 800,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 100
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 800,
"currency": "USD"
}
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 1050,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 1040,
"currency": "USD"
}
}
],
"processNote": [
{
"number": 101,
"type": "print",
"text": "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
],
"insurance": [
{
"sequence": 1,
"focal": true,
"coverage": {
"reference": "Coverage/9876B1"
}
}
]
}
Example #5
Input CSV
ClaimResponse,5,"R3502","active","http://terminology.hl7.org/CodeSystem/claim-type",,"vision",,,,,,,,,,"claim","Patient/1",,,,,,,,,,,,,,"2014-08-16","Organization/2",,,,,,,,,,,,,,"Organization/1",,,,,,,,,,,,,,,,,,,,,,,"http://happysight.com/claim","6612346",,,,"complete","Claim settled as per contract.",,,,"http://terminology.hl7.org/CodeSystem/payeetype",,"provider",,,,"http://terminology.hl7.org/CodeSystem/ex-paymenttype",,"complete",,,,75,"USD","http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",,"a002","Prior Overpayment",,,"2014-08-16",107,"USD",,,,,,,,"http://thebenefitcompany.com/paymentidentifier","201416-123456",,,,,,,,,,,,,,,,,,,,,,
identifier,,,,,,,,"http://thebenefitcompany.com/claimresponse","CR6532875367",,
item,1,,,,"eligible",,,,,,,,,,235.4,"USD",,1,1,,,"eligible",,,,,,,,,,100,"USD",,,,,,,,,,,,,,,,,,
total,,,"submitted",,,,235.4,"USD"
total,,,"benefit",,,,182,"USD"
processNote,1,"display","After hours surcharge declined","urn:ietf:bcp:47",,"en-CA",,,
Resulting resource
{
"resourceType": "ClaimResponse",
"id": "R3502",
"identifier": [
{
"system": "http://thebenefitcompany.com/claimresponse",
"value": "CR6532875367"
}
],
"status": "active",
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/claim-type",
"code": "vision"
}
]
},
"use": "claim",
"patient": {
"reference": "Patient/1"
},
"created": "2014-08-16",
"insurer": {
"reference": "Organization/2"
},
"requestor": {
"reference": "Organization/1"
},
"request": {
"identifier": {
"system": "http://happysight.com/claim",
"value": "6612346"
}
},
"outcome": "complete",
"disposition": "Claim settled as per contract.",
"payeeType": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payeetype",
"code": "provider"
}
]
},
"item": [
{
"itemSequence": 1,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 235.4,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 20,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 172.32,
"currency": "USD"
}
}
],
"detail": [
{
"detailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 100,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "copay"
}
]
},
"amount": {
"value": 20,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 80,
"currency": "USD"
}
}
]
},
{
"detailSequence": 2,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 110,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 88,
"currency": "USD"
}
}
],
"subDetail": [
{
"subDetailSequence": 1,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 60,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 48,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 2,
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 30,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 24,
"currency": "USD"
}
}
]
},
{
"subDetailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 10,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 8,
"currency": "USD"
}
}
]
}
]
},
{
"detailSequence": 3,
"noteNumber": [
1
],
"adjudication": [
{
"category": {
"coding": [
{
"code": "eligible"
}
]
},
"amount": {
"value": 200,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "eligpercent"
}
]
},
"value": 80
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 14,
"currency": "USD"
}
}
]
}
]
}
],
"total": [
{
"category": {
"coding": [
{
"code": "submitted"
}
]
},
"amount": {
"value": 235.4,
"currency": "USD"
}
},
{
"category": {
"coding": [
{
"code": "benefit"
}
]
},
"amount": {
"value": 182,
"currency": "USD"
}
}
],
"payment": {
"type": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/ex-paymenttype",
"code": "complete"
}
]
},
"adjustment": {
"value": 75,
"currency": "USD"
},
"adjustmentReason": {
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/payment-adjustment-reason",
"code": "a002",
"display": "Prior Overpayment"
}
]
},
"date": "2014-08-16",
"amount": {
"value": 107,
"currency": "USD"
},
"identifier": {
"system": "http://thebenefitcompany.com/paymentidentifier",
"value": "201416-123456"
}
},
"processNote": [
{
"number": 1,
"type": "display",
"text": "After hours surcharge declined",
"language": {
"coding": [
{
"system": "urn:ietf:bcp:47",
"code": "en-CA"
}
]
}
}
]
}