Healthcare Financial Services IG Edition 1 - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: Nphies Claim Response

Nphies Claim Response Profile

Usages:

• Refer to this Profile: Nphies Claim (base), Nphies Claim Response and Nphies Payment Reconciliation
• Examples for this Profile: ClaimResponse/293094 and ClaimResponse/48100

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.status	required	Pattern Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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
identifier		1..1	DP_Identifier_A	Business Identifier for a claim response
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)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 Bindings Purpose 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	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	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	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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
ClaimResponse.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	Pattern Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.patient.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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:

• DP_canonical (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-canonical)
• DP_Identifier_A (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Identifier-A)
• DP_code (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-code)
• DP_CodeableConcept (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-CodeableConcept)
• DP_Reference_1or2a (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1or2a)
• Nphies Patient (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient)
• DP_dateTime (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-dateTime)
• Nphies Insurer Organization (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization)
• Nphies Provider Organization (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization)
• DP_Reference_1or3a (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1or3a)
• Nphies Claim (base) (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-base)
• DP_string (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-string)
• DP_Period_2 (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Period-2)
• DP_positiveInt (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-positiveInt)
• DP_Money_SAR (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Money-SAR)
• DP_decimal (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-decimal)
• Nphies CommunicationRequest (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/communication-request)
• DP_Reference_1 (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1)
• Nphies Claim Response (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-response)

Extensions

This structure refers to these extensions:

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.status	required	Pattern Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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
identifier		1..1	DP_Identifier_A	Business Identifier for a claim response
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)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 Bindings Purpose 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	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	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	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)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
ClaimResponse.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
ClaimResponse.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	Pattern Value: active http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	required	ClaimTypeCodes http://nphies.sa/terminology/ValueSet/claim-type From this IG
ClaimResponse.subType	required	ClaimSubType(a valid code from Claim SubType) http://nphies.sa/terminology/ValueSet/claim-subtype From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
ClaimResponse.patient.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|4.0.1 From the FHIR Standard
ClaimResponse.patient.identifier.type	required	PatientIdentifierType http://nphies.sa/terminology/ValueSet/patient-identifier-type From this IG
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	required	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.item.detail.subDetail.adjudication.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.item.detail.subDetail.adjudication.reason	required	AdjudicationReason(a valid code from Adjudication Reason) http://nphies.sa/terminology/ValueSet/adjudication-reason From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	required	Adjudication http://nphies.sa/terminology/ValueSet/adjudication From this IG
ClaimResponse.payment.type	example	ExamplePaymentTypeCodes http://hl7.org/fhir/ValueSet/ex-paymenttype From the FHIR Standard
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	required	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	required	KSALanguages http://nphies.sa/terminology/ValueSet/ksa-languages From this IG
ClaimResponse.error.code	required	AdjudicationError(a valid code from Adjudication Error) http://nphies.sa/terminology/ValueSet/adjudication-error From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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:

• DP_canonical (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-canonical)
• DP_Identifier_A (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Identifier-A)
• DP_code (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-code)
• DP_CodeableConcept (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-CodeableConcept)
• DP_Reference_1or2a (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1or2a)
• Nphies Patient (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/patient)
• DP_dateTime (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-dateTime)
• Nphies Insurer Organization (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/insurer-organization)
• Nphies Provider Organization (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/provider-organization)
• DP_Reference_1or3a (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1or3a)
• Nphies Claim (base) (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-base)
• DP_string (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-string)
• DP_Period_2 (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Period-2)
• DP_positiveInt (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-positiveInt)
• DP_Money_SAR (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Money-SAR)
• DP_decimal (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-decimal)
• Nphies CommunicationRequest (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/communication-request)
• DP_Reference_1 (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/DP-Reference-1)
• Nphies Claim Response (http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/claim-response)

Extensions

This structure refers to these extensions:

• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-reissue
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-adjudication-outcome
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-identifier
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-number
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-batch-period
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-patientInvoice
• http://nphies.sa/fhir/ksa/nphies-fs/StructureDefinition/extension-error-expression