Healthcare Financial Services IG Edition 1
0.4.0 - STU-Ballot with Updates Saudi Arabia flag

Healthcare Financial Services IG Edition 1 - Local Development build (v0.4.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: Nphies Claim Response

Official URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-response Version: 0.4.0
Draft as of 2025-10-12 Computable Name: NphiesClaimResponse

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

Nphies Claim Response Profile

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id Σ 1..1 id Logical id of this artifact
Max Length:64
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 DP_Identifier_A Business Identifier for a claim response
... status ?!Σ 1..1 DP_code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type Σ 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use Σ 1..1 DP_code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient Σ 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
Max Length:250
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
..... system Σ 1..1 DP_uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 1..1 string The value that is unique
Example General: 123456
Max Length:50
.... display Σ 0..1 string Text alternative for the resource
Max Length:200
... created Σ 1..1 DP_dateTime Response creation date
... insurer Σ 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request Σ 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome Σ 1..1 DP_code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... total SΣ 0..* BackboneElement Adjudication totals
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount ΣC 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id 1..1 id Logical id of this artifact
Max Length:64
... meta 1..1 Meta Metadata about the resource
.... profile 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... status 1..1 DP_code active | cancelled | draft | entered-in-error
Required Pattern: active
... type 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use 1..1 DP_code claim | preauthorization | predetermination
... patient 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... identifier
..... type 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
... created 1..1 DP_dateTime Response creation date
... insurer 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome 1..1 DP_code queued | complete | error | partial
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... total S 0..* BackboneElement Adjudication totals
.... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount C 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id Σ 1..1 id Logical id of this artifact
Max Length:64
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 DP_Identifier_A Business Identifier for a claim response
... status ?!Σ 1..1 DP_code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type Σ 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use Σ 1..1 DP_code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient Σ 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
Max Length:250
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
..... system Σ 1..1 DP_uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 1..1 string The value that is unique
Example General: 123456
Max Length:50
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
Max Length:200
... created Σ 1..1 DP_dateTime Response creation date
... insurer Σ 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request Σ 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome Σ 1..1 DP_code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
.... detail 0..* BackboneElement Insurer added line details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total SΣ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount ΣC 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 1..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.patient.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 7 elements(3 nested mandatory elements)
Must-Support: 38 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id Σ 1..1 id Logical id of this artifact
Max Length:64
... meta Σ 1..1 Meta Metadata about the resource
.... profile Σ 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 DP_Identifier_A Business Identifier for a claim response
... status ?!Σ 1..1 DP_code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type Σ 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use Σ 1..1 DP_code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient Σ 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
Max Length:250
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
..... system Σ 1..1 DP_uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 1..1 string The value that is unique
Example General: 123456
Max Length:50
.... display Σ 0..1 string Text alternative for the resource
Max Length:200
... created Σ 1..1 DP_dateTime Response creation date
... insurer Σ 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request Σ 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome Σ 1..1 DP_code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... total SΣ 0..* BackboneElement Adjudication totals
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount ΣC 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id 1..1 id Logical id of this artifact
Max Length:64
... meta 1..1 Meta Metadata about the resource
.... profile 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... status 1..1 DP_code active | cancelled | draft | entered-in-error
Required Pattern: active
... type 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use 1..1 DP_code claim | preauthorization | predetermination
... patient 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... identifier
..... type 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
... created 1..1 DP_dateTime Response creation date
... insurer 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome 1..1 DP_code queued | complete | error | partial
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... total S 0..* BackboneElement Adjudication totals
.... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount C 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... processNote S 0..* BackboneElement Note concerning adjudication
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse C 0..* ClaimResponse Response to a claim predetermination or preauthorization
Constraints: BV-00023, BV-00045, BV-00147, BV-00228, BV-00232, BV-00334, BV-00492B, BV-00505, BV-00524, BV-00853, BV-00854
... id Σ 1..1 id Logical id of this artifact
Max Length:64
... meta Σ 1..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* DP_canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:reissue-reason S 0..1 CodeableConcept Adjudication Reissue Reason
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
Binding: Reissue Reason (required)
.... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
.... extension:batch-identifier S 0..1 DP_Identifier_A Claim Batch Identifier
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
.... extension:batch-number S 0..1 DP_positiveInt Claim Batch Number
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
.... extension:batch-period S 0..1 DP_Period_2 Claim Batch Period
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 1..1 DP_Identifier_A Business Identifier for a claim response
... status ?!Σ 1..1 DP_code active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
Required Pattern: active
... type Σ 1..1 DP_CodeableConcept More granular claim type
Binding: Claim Type Codes (required)
... subType 1..1 DP_CodeableConcept More granular claim type
Binding: Claim SubType (required)
... use Σ 1..1 DP_code claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient Σ 1..1 DP_Reference_1or2a(Nphies Patient) The recipient of the products and services
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Literal reference, Relative, internal or absolute URL
Max Length:250
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier SΣ 0..1 Identifier Logical reference, when literal reference is not known
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 1..1 DP_CodeableConcept Description of identifier
Binding: Patient Identifier Type (required)
..... system Σ 1..1 DP_uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value Σ 1..1 string The value that is unique
Example General: 123456
Max Length:50
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
Max Length:200
... created Σ 1..1 DP_dateTime Response creation date
... insurer Σ 1..1 DP_Reference_1or2a(Nphies Insurer Organization) Party responsible for reimbursement
... requestor 1..1 DP_Reference_1or2a(Nphies Provider Organization) Party responsible for the claim
... request Σ 1..1 DP_Reference_1or3a(Nphies Claim (base)) Id of resource triggering adjudication
... outcome Σ 1..1 DP_code queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... disposition S 0..1 DP_string Disposition Message
... preAuthRef S 0..1 DP_string Preauthorization reference
... preAuthPeriod S 0..1 DP_Period_2 Preauthorization reference effective period
... payeeType S 0..1 DP_CodeableConcept Party to be paid any benefits payable
Binding: Claim Payee Type Codes (required)
... item SC 0..* BackboneElement Adjudication for claim line items
Constraints: BV-00025, BV-00391, BV-00521
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:adjudication-outcome S 0..1 CodeableConcept Adjudication Outcome
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
Binding: Adjudication Outcome (required)
..... extension:patientInvoice S 0..1 DP_Identifier_A Patient Invoice
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 DP_positiveInt Claim item instance identifier
.... noteNumber S 0..* DP_positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Adjudication details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
..... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
..... amount SC 0..1 DP_Money_SAR Monetary amount
Constraints: BV-00458
..... value S 0..1 DP_decimal Non-monetary value
.... detail SC 0..* BackboneElement Adjudication for claim details
Constraints: BV-00069, BV-00522
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 DP_positiveInt Claim detail instance identifier
..... noteNumber S 0..* DP_positiveInt Applicable note numbers
..... adjudication 1..* BackboneElement Detail level adjudication details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
...... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
...... amount S 0..1 DP_Money_SAR Monetary amount
...... value S 0..1 DP_decimal Non-monetary value
..... subDetail SC 0..* BackboneElement Adjudication for claim sub-details
Constraints: BV-00523
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 DP_positiveInt Claim sub-detail instance identifier
...... noteNumber S 0..* DP_positiveInt Applicable note numbers
...... adjudication 1..* BackboneElement Subdetail level adjudication details
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
....... category 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
....... reason S 0..1 DP_CodeableConcept Explanation of adjudication outcome
Binding: Adjudication Reason (required)
....... amount S 0..1 DP_Money_SAR Monetary amount
....... value S 0..1 DP_decimal Non-monetary value
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
.... programCode 0..* CodeableConcept Program the product or service is provided under
Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
.... serviced[x] 0..1 Date or dates of service or product delivery
..... servicedDate date
..... servicedPeriod Period
.... location[x] 0..1 Place of service or where product was supplied
Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
..... locationCodeableConcept CodeableConcept
..... locationAddress Address
..... locationReference Reference(Location)
.... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
.... unitPrice 0..1 Money Fee, charge or cost per item
.... factor 0..1 decimal Price scaling factor
.... net 0..1 Money Total item cost
.... bodySite 0..1 CodeableConcept Anatomical location
Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* See adjudication (ClaimResponse) Added items adjudication
.... detail 0..* BackboneElement Insurer added line details
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
..... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
..... unitPrice 0..1 Money Fee, charge or cost per item
..... factor 0..1 decimal Price scaling factor
..... net 0..1 Money Total item cost
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
..... subDetail 0..* BackboneElement Insurer added line items
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Binding: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
...... quantity 0..1 SimpleQuantity(4.0.1) Count of products or services
...... unitPrice 0..1 Money Fee, charge or cost per item
...... factor 0..1 decimal Price scaling factor
...... net 0..1 Money Total item cost
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 1..* See adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* See adjudication (ClaimResponse) Header-level adjudication
... total SΣ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 DP_CodeableConcept Type of adjudication information
Binding: Adjudication (required)
.... amount ΣC 1..1 DP_Money_SAR Financial total for the category
Constraints: BV-00229
... payment 0..1 BackboneElement Payment Details
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Partial or complete payment
Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 1..1 Money Payable amount after adjustment
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve S 0..1 CodeableConcept Funds reserved status
Binding: Funds Reservation Codes (required)
... formCode 0..1 CodeableConcept Printed form identifier
Binding: Form Codes (example): The forms codes.
... form 0..1 Attachment Printed reference or actual form
... processNote S 0..* BackboneElement Note concerning adjudication
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... number 1..1 DP_positiveInt Note instance identifier
.... type 1..1 DP_code display | print | printoper
Binding: NoteType (required): The presentation types of notes.
.... text 1..1 DP_string Note explanatory text
.... language S 0..1 DP_CodeableConcept Language of the text
Binding: KSA Languages (required)
... communicationRequest S 0..* Reference(Nphies CommunicationRequest) Request for additional information
... insurance S 0..* BackboneElement Patient insurance information
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... sequence 1..1 DP_positiveInt Insurance instance identifier
.... focal 1..1 boolean Coverage to be used for adjudication
.... coverage 1..1 DP_Reference_1(Coverage) Insurance information
.... businessArrangement 0..1 string Additional provider contract number
.... claimResponse S 0..1 DP_Reference_1or3a(Nphies Claim Response) Adjudication results
... error S 0..* BackboneElement Processing errors
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
..... extension:expression S 0..1 string Error Expression
URL: http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 0..1 DP_positiveInt Item sequence number
.... detailSequence S 0..1 DP_positiveInt Detail sequence number
.... subDetailSequence S 0..1 DP_positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Error code detailing processing issues
Binding: Adjudication Error Codes (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
ClaimResponse.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base required Claim Type Codes 📦0.4.0 This IG
ClaimResponse.subType Base required Claim SubType 📦0.4.0 This IG
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.patient.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
ClaimResponse.patient.​identifier.type Base required Patient Identifier Type 📦0.4.0 This IG
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base required PayeeType 📦4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​adjudication.reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.item.detail.​subDetail.adjudication.​reason Base required Adjudication Reason 📦0.4.0 This IG
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base required Adjudication 📦0.4.0 This IG
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base required FundsReserve 📦4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base required KSA Languages 📦0.4.0 This IG
ClaimResponse.error.​code Base required Adjudication Error Codes 📦0.4.0 This IG

Constraints

Id Grade Path(s) Description Expression
BV-00023 error ClaimResponse ClaimResponse total is not provided when ClaimResponse outcome is not equal to error. (outcome.exists() and outcome!='error') implies total.exists()
BV-00025 error ClaimResponse.item ClaimResponse item detailSequence in claim response is not unique within the ClaimResponse item. detail.detailSequence.isDistinct()
BV-00045 error ClaimResponse ClaimResponse item sequence value is not unique within the ClaimResponse resource. item.itemSequence.isDistinct()
BV-00069 error ClaimResponse.item.detail ClaimResponse item detail subdetailSequence is not unique in the ClaimResponse item detail. subDetail.subDetailSequence.isDistinct()
BV-00147 error ClaimResponse The ClaimResponse Identifier is not provided. identifier.exists()
BV-00228 error ClaimResponse ClaimResponse shall not contain any items since the outcome is 'queued' or 'error'. outcome.exists() implies (outcome = 'queued' or outcome = 'error') implies item.count() = 0
BV-00229 error ClaimResponse.total.amount ClaimResponse total amount currency is not SAR. currency = 'SAR'
BV-00232 error ClaimResponse ClaimResponse status is not 'active'. status.exists() implies status = 'active'
BV-00334 error ClaimResponse Claim Response use is not using the specified value 'claim'. use.exists() implies use='claim'
BV-00391 error ClaimResponse.item ClaimResponse item adjudication category is not unique for the supplied ClaimResponse item. adjudication.category.isDistinct()
BV-00458 error ClaimResponse.item.adjudication.amount Item adjudication amount currency must be 'SAR'. currency = 'SAR'
BV-00492B error ClaimResponse The payee type can only be one of ('provider', 'other') in a claim or claim response. payeeType.exists() implies (payeeType.coding.first().code = 'provider' or payeeType.coding.first().code = 'other')
BV-00505 error ClaimResponse The error details are required when outcome is 'error'. outcome.exists() implies outcome='error' implies error.exists()
BV-00521 error ClaimResponse.item The item noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00522 error ClaimResponse.item.detail The item detail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00523 error ClaimResponse.item.detail.subDetail The item subdetail noteNumber shall be unique within the list of items. noteNumber.exists() implies noteNumber.isDistinct()
BV-00524 error ClaimResponse ClaimResponse processNote number shall be unique within the list of processNotes. processNote.number.exists() implies processNote.number.isDistinct()
BV-00853 error ClaimResponse Insurance shall be provided for complete Claims and Authorization. insurance.exists()
BV-00854 error ClaimResponse One and only one focal Insurance Shall be provided for Claim and Authorization. insurance.exists() implies insurance.focal.count() = 1
dom-2 error ClaimResponse If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error ClaimResponse If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error ClaimResponse If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice ClaimResponse A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 7 elements(3 nested mandatory elements)
Must-Support: 38 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron