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13.7 Ресурс ClaimResponse - Назначение

Financial Management Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Patient, Practitioner

Этот ресурс предоставляет информацию о вынесенном решении по результату обработки ресурса Claim.

Ресурс ClaimResponse содержит либо результаты судебного решения, либо ошибку прикладного уровня, которые являются результатом обработки предъявленного ресурса Claim, где Claim может быть функциональным следствием иска, предварительного определения или предварительного санкционирования.

Это признанный судебными органами ответ на иск, предварительное определение или предварительное санкционирование. Сила платежного аспекта ответа соответствует силе первоначального запроса. Для иска (Claim) вынесение решения означает платеж, который предназначен быть совершенным, для предварительного санкционирования и предварительного определения никакой платеж на самом деле не будет сделан, однако могут быть зарезервированы денежные средства для урегулирования иска, выставленного впоследствии. Только фактические иски влекут за собой фактическую оплату.

Ресурс ClaimResponse является ответом на предъявление: Claim, Re-adjudication и Reversals.

The ClaimResponse may have been created by interpreting the corresponding Claim resource as a request for payment (the oldest sense of a claim), a request for preauthorization or a request for predetermination. These interpretations are described at the Claim resource. It is possible for the consumer of the ClaimResponse resource to know the manner in which the Claim resource was processed by checking the Claim.use code.

Where the producer of the ClaimResponse resource interpreted the Claim as a traditional claim, the contents of the ClaimResponse includes information that the producer of the ClaimResponse intends to pay. The actual payment, however, is conveyed separately, perhaps through an eletronic funds transfer protocol outside the domain of FHIR or possibly by a paper check.

However, when the producer of the ClaimResponse interpreted the Claim as request for preauthorization or predetermination, the ClaimResponse does not imply that such a payment is pending. Actual payment would only follow the interpretation fo a Claim resource as a traditional claim.

На этот ресурс ссылаются Claim, itself, DeviceRequest, ExplanationOfBenefit, MedicationRequest, ServiceRequest и Task

Структура

ИмяФлагиКард.ТипОписание и ограниченияdoco
.. ClaimResponse TUDomainResourceResponse to a claim predetermination or preauthorization
Элементы, определённые в прародителе: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse Дата создания
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Идентификатор ресурса, инициировавшего решение по иску
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringСообщение о возможности воспользоваться
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptСторона, которой необходимо выплатить все подлежащие оплате выгоды
PayeeType (Example)
... item 0..*BackboneElementAdjudication for claim line items
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementДетали вынесения решения
..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyДенежная сумма
..... value 0..1decimalНеденежное значение
.... detail 0..*BackboneElementAdjudication for claim details
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementТоварные позиции, добавленные страховой компанией
.... itemSequence 0..*positiveIntПорядковый номер пункта
.... detailSequence 0..*positiveIntПодробный порядковый номер
.... subdetailSequence 0..*positiveIntСведения о порядковом номере
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*see adjudicationВынесенное решение по добавленным пунктам
.... detail 0..*BackboneElementInsurer added line details
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationСудебное решение по добавленным пунктам
..... subDetail 0..*BackboneElementТоварные позиции, добавленные страховой компанией
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*see adjudicationСудебное решение по добавленным пунктам
... adjudication 0..*see adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyСогласование платежей по не связанным с иском вопросам
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptСтатус зарезервированных денежных средств
FundsReserve (Example)
... formCode 0..1CodeableConceptИдентификатор формы, которую необходимо использовать для печати
Forms (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 1..1stringПояснительный текст примечания
.... language 0..1CodeableConceptLanguage of the text
Language (Preferred but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Информация по страховке
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Результаты вынесения решения
... error 0..*BackboneElementОшибки обработки
.... itemSequence 0..1positiveIntПорядковый номер пункта
.... detailSequence 0..1positiveIntПодробный порядковый номер
.... subDetailSequence 0..1positiveIntСведения о порядковом номере
.... code 1..1CodeableConceptКод ошибки, подробно описывающий проблемы обработки
AdjudicationError (Example)

doco Документация по этому формату

UML-диаграмма (Legend)

ClaimResponse (DomainResource)A unique identifier assigned to this claim responseidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicetype : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the futureuse : code [1..1] « Claim, preauthorization, predetermination. (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimburement is soughtpatient : Reference [1..1] « Patient »The date this resource was createdcreated : dateTime [1..1]The party responsible for authorization, adjudication and reimbursementinsurer : Reference [1..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « Claim »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « The result of the claim processing. (Strength=Required)ClaimProcessingCodes! »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]Type of Сторона, которой должно быть выплачено возмещение: подписчик, поставщик, другаяpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »A code for Форма, которую необходимо использовать для печати данного содержимогоformCode : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]Request for additional supporting or authorizing informationcommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA number to uniquely reference the claim item entriesitemSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AdjudicationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « Коды вынесенного решения. (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « Коды обоснования вынесенного решения. (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA number to uniquely reference the claim detail entrydetailSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]SubDetailA number to uniquely reference the claim sub-detail entrysubDetailSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details woithin the details within the claim item which this line is intended to replacesubdetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the product or service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemSubDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]TotalA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « Коды вынесенного решения. (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [1..1] « The type (partial, complete) of the payment. (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Причина корректировки платежаadjustmentReason : CodeableConcept [0..1] « Коды обоснования вынесенного решения по платежам. (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits Сумма, подлежащая оплате, меньшая, чем любая корректировка оплатыamount : Money [1..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the Текст примечанияtype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The explanation or description associated with the processingtext : string [1..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « Естественный язык. (Strength=Preferred)Common Languages? »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »A Деловое соглашениеnumber established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structureitemSequence : positiveInt [0..1]The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structuredetailSequence : positiveInt [0..1]The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structuresubDetailSequence : positiveInt [0..1]An error code, from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « Коды ошибок в процессе вынесения решения. (Strength=Example)Adjudication Error ?? »If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this itemadjudication[1..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[0..*]A sub-detail adjudication of a simple product or servicesubDetail[0..*]A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-detailsitem[0..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[1..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Errors encountered during the processing of the adjudicationerror[0..*]

XML-шаблон

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response Дата создания -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Идентификатор ресурса, инициировавшего решение по иску --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Сообщение о возможности воспользоваться -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Сторона, которой необходимо выплатить все подлежащие оплате выгоды --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Детали вынесения решения -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Денежная сумма --></amount>
   <value value="[decimal]"/><!-- 0..1 Неденежное значение -->
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Товарные позиции, добавленные страховой компанией -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Порядковый номер пункта -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Подробный порядковый номер -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Сведения о порядковом номере -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Вынесенное решение по добавленным пунктам --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Судебное решение по добавленным пунктам --></adjudication>
   <subDetail>  <!-- 0..* Товарные позиции, добавленные страховой компанией -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Судебное решение по добавленным пунктам --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Согласование платежей по не связанным с иском вопросам --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Статус зарезервированных денежных средств --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Идентификатор формы, которую необходимо использовать для печати --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Пояснительный текст примечания -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Информация по страховке --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Результаты вынесения решения --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Ошибки обработки -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Порядковый номер пункта -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Подробный порядковый номер -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Сведения о порядковом номере -->
  <code><!-- 1..1 CodeableConcept Код ошибки, подробно описывающий проблемы обработки --></code>
 </error>
</ClaimResponse>

JSON-шаблон

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response Дата создания
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Идентификатор ресурса, инициировавшего решение по иску
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Сообщение о возможности воспользоваться
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Сторона, которой необходимо выплатить все подлежащие оплате выгоды
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Детали вынесения решения
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Денежная сумма
      "value" : <decimal> // Неденежное значение
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Товарные позиции, добавленные страховой компанией
    "itemSequence" : ["<positiveInt>"], // Порядковый номер пункта
    "detailSequence" : ["<positiveInt>"], // Подробный порядковый номер
    "subdetailSequence" : ["<positiveInt>"], // Сведения о порядковом номере
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Вынесенное решение по добавленным пунктам
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Судебное решение по добавленным пунктам
      "subDetail" : [{ // Товарные позиции, добавленные страховой компанией
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Судебное решение по добавленным пунктам
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Согласование платежей по не связанным с иском вопросам
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Статус зарезервированных денежных средств
  "formCode" : { CodeableConcept }, // Идентификатор формы, которую необходимо использовать для печати
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Пояснительный текст примечания
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Информация по страховке
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Результаты вынесения решения
  }],
  "error" : [{ // Ошибки обработки
    "itemSequence" : "<positiveInt>", // Порядковый номер пункта
    "detailSequence" : "<positiveInt>", // Подробный порядковый номер
    "subDetailSequence" : "<positiveInt>", // Сведения о порядковом номере
    "code" : { CodeableConcept } // R!  Код ошибки, подробно описывающий проблемы обработки
  }]
}

Turtle-шаблон

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response Дата создания
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Идентификатор ресурса, инициировавшего решение по иску
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Сообщение о возможности воспользоваться
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Сторона, которой необходимо выплатить все подлежащие оплате выгоды
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Детали вынесения решения
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Денежная сумма
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Неденежное значение
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Товарные позиции, добавленные страховой компанией
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Порядковый номер пункта
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Подробный порядковый номер
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Сведения о порядковом номере
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Вынесенное решение по добавленным пунктам
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Судебное решение по добавленным пунктам
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Товарные позиции, добавленные страховой компанией
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Судебное решение по добавленным пунктам
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Согласование платежей по не связанным с иском вопросам
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Статус зарезервированных денежных средств
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Идентификатор формы, которую необходимо использовать для печати
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Пояснительный текст примечания
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Информация по страховке
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Результаты вынесения решения
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Ошибки обработки
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Порядковый номер пункта
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Подробный порядковый номер
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Сведения о порядковом номере
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Код ошибки, подробно описывающий проблемы обработки
  ], ...;
]

Changes since R3

ClaimResponse
ClaimResponse.status
  • Min Cardinality changed from 0 to 1
ClaimResponse.type
  • Added Mandatory Element
ClaimResponse.subType
  • Added Element
ClaimResponse.use
  • Added Mandatory Element
ClaimResponse.patient
  • Min Cardinality changed from 0 to 1
ClaimResponse.created
  • Min Cardinality changed from 0 to 1
ClaimResponse.insurer
  • Min Cardinality changed from 0 to 1
ClaimResponse.requestor
  • Added Element
ClaimResponse.outcome
  • Min Cardinality changed from 0 to 1
  • Type changed from CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.preAuthRef
  • Added Element
ClaimResponse.preAuthPeriod
  • Added Element
ClaimResponse.item.itemSequence
  • Added Mandatory Element
ClaimResponse.item.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.item.detail.detailSequence
  • Added Mandatory Element
ClaimResponse.item.detail.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Mandatory Element
ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.provider
  • Added Element
ClaimResponse.addItem.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.programCode
  • Added Element
ClaimResponse.addItem.serviced[x]
  • Added Element
ClaimResponse.addItem.location[x]
  • Added Element
ClaimResponse.addItem.quantity
  • Added Element
ClaimResponse.addItem.unitPrice
  • Added Element
ClaimResponse.addItem.factor
  • Added Element
ClaimResponse.addItem.net
  • Added Element
ClaimResponse.addItem.bodySite
  • Added Element
ClaimResponse.addItem.subSite
  • Added Element
ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.addItem.detail.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.detail.quantity
  • Added Element
ClaimResponse.addItem.detail.unitPrice
  • Added Element
ClaimResponse.addItem.detail.factor
  • Added Element
ClaimResponse.addItem.detail.net
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.addItem.detail.subDetail
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.detail.subDetail.modifier
  • Added Element
ClaimResponse.addItem.detail.subDetail.quantity
  • Added Element
ClaimResponse.addItem.detail.subDetail.unitPrice
  • Added Element
ClaimResponse.addItem.detail.subDetail.factor
  • Added Element
ClaimResponse.addItem.detail.subDetail.net
  • Added Element
ClaimResponse.addItem.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication
  • Added Mandatory Element
ClaimResponse.adjudication
  • Added Element
ClaimResponse.total
  • Added Element
ClaimResponse.total.category
  • Added Mandatory Element
ClaimResponse.total.amount
  • Added Mandatory Element
ClaimResponse.payment.type
  • Min Cardinality changed from 0 to 1
ClaimResponse.payment.amount
  • Min Cardinality changed from 0 to 1
ClaimResponse.fundsReserve
  • Added Element
ClaimResponse.formCode
  • Added Element
ClaimResponse.form
  • Type changed from CodeableConcept to Attachment
ClaimResponse.processNote.type
  • Type changed from CodeableConcept to code
ClaimResponse.processNote.text
  • Min Cardinality changed from 0 to 1
ClaimResponse.processNote.language
  • Change binding strength from extensible to preferred
ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.requestProvider
  • deleted
ClaimResponse.requestOrganization
  • deleted
ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.addItem.revenue
  • deleted
ClaimResponse.addItem.category
  • deleted
ClaimResponse.addItem.service
  • deleted
ClaimResponse.addItem.fee
  • deleted
ClaimResponse.addItem.detail.revenue
  • deleted
ClaimResponse.addItem.detail.category
  • deleted
ClaimResponse.addItem.detail.service
  • deleted
ClaimResponse.addItem.detail.fee
  • deleted
ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.totalCost
  • deleted
ClaimResponse.unallocDeductable
  • deleted
ClaimResponse.totalBenefit
  • deleted
ClaimResponse.reserved
  • deleted
ClaimResponse.insurance.preAuthRef
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)

Структура

ИмяФлагиКард.ТипОписание и ограниченияdoco
.. ClaimResponse TUDomainResourceResponse to a claim predetermination or preauthorization
Элементы, определённые в прародителе: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierBusiness Identifier for a claim response
... status ?!Σ1..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... type Σ1..1CodeableConceptMore granular claim type
Claim Type Codes (Extensible)
... subType 0..1CodeableConceptMore granular claim type
Example Claim SubType Codes (Example)
... use Σ1..1codeclaim | preauthorization | predetermination
Use (Required)
... patient Σ1..1Reference(Patient)The recipient of the products and services
... created Σ1..1dateTimeResponse Дата создания
... insurer Σ1..1Reference(Organization)Party responsible for reimbursement
... requestor 0..1Reference(Practitioner | PractitionerRole | Organization)Party responsible for the claim
... request Σ0..1Reference(Claim)Идентификатор ресурса, инициировавшего решение по иску
... outcome Σ1..1codequeued | complete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringСообщение о возможности воспользоваться
... preAuthRef 0..1stringPreauthorization reference
... preAuthPeriod 0..1PeriodPreauthorization reference effective period
... payeeType 0..1CodeableConceptСторона, которой необходимо выплатить все подлежащие оплате выгоды
PayeeType (Example)
... item 0..*BackboneElementAdjudication for claim line items
.... itemSequence 1..1positiveIntClaim item instance identifier
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*BackboneElementДетали вынесения решения
..... category 1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyДенежная сумма
..... value 0..1decimalНеденежное значение
.... detail 0..*BackboneElementAdjudication for claim details
..... detailSequence 1..1positiveIntClaim detail instance identifier
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementAdjudication for claim sub-details
...... subDetailSequence 1..1positiveIntClaim sub-detail instance identifier
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementТоварные позиции, добавленные страховой компанией
.... itemSequence 0..*positiveIntПорядковый номер пункта
.... detailSequence 0..*positiveIntПодробный порядковый номер
.... subdetailSequence 0..*positiveIntСведения о порядковом номере
.... provider 0..*Reference(Practitioner | PractitionerRole | Organization)Authorized providers
.... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... programCode 0..*CodeableConceptProgram the product or service is provided under
Example Program Reason Codes (Example)
.... serviced[x] 0..1Date or dates of service or product delivery
..... servicedDatedate
..... servicedPeriodPeriod
.... location[x] 0..1Place of service or where product was supplied
Example Service Place Codes (Example)
..... locationCodeableConceptCodeableConcept
..... locationAddressAddress
..... locationReferenceReference(Location)
.... quantity 0..1SimpleQuantityCount of products or services
.... unitPrice 0..1MoneyFee, charge or cost per item
.... factor 0..1decimalPrice scaling factor
.... net 0..1MoneyTotal item cost
.... bodySite 0..1CodeableConceptAnatomical location
Oral Site Codes (Example)
.... subSite 0..*CodeableConceptAnatomical sub-location
Surface Codes (Example)
.... noteNumber 0..*positiveIntApplicable note numbers
.... adjudication 1..*see adjudicationВынесенное решение по добавленным пунктам
.... detail 0..*BackboneElementInsurer added line details
..... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... quantity 0..1SimpleQuantityCount of products or services
..... unitPrice 0..1MoneyFee, charge or cost per item
..... factor 0..1decimalPrice scaling factor
..... net 0..1MoneyTotal item cost
..... noteNumber 0..*positiveIntApplicable note numbers
..... adjudication 1..*see adjudicationСудебное решение по добавленным пунктам
..... subDetail 0..*BackboneElementТоварные позиции, добавленные страховой компанией
...... productOrService 1..1CodeableConceptBilling, service, product, or drug code
USCLS Codes (Example)
...... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
...... quantity 0..1SimpleQuantityCount of products or services
...... unitPrice 0..1MoneyFee, charge or cost per item
...... factor 0..1decimalPrice scaling factor
...... net 0..1MoneyTotal item cost
...... noteNumber 0..*positiveIntApplicable note numbers
...... adjudication 1..*see adjudicationСудебное решение по добавленным пунктам
... adjudication 0..*see adjudicationHeader-level adjudication
... total Σ0..*BackboneElementAdjudication totals
.... category Σ1..1CodeableConceptType of adjudication information
Adjudication Value Codes (Example)
.... amount Σ1..1MoneyFinancial total for the category
... payment 0..1BackboneElementPayment Details
.... type 1..1CodeableConceptPartial or complete payment
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyСогласование платежей по не связанным с иском вопросам
.... adjustmentReason 0..1CodeableConceptExplanation for the adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected date of payment
.... amount 1..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierBusiness identifier for the payment
... fundsReserve 0..1CodeableConceptСтатус зарезервированных денежных средств
FundsReserve (Example)
... formCode 0..1CodeableConceptИдентификатор формы, которую необходимо использовать для печати
Forms (Example)
... form 0..1AttachmentPrinted reference or actual form
... processNote 0..*BackboneElementNote concerning adjudication
.... number 0..1positiveIntNote instance identifier
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 1..1stringПояснительный текст примечания
.... language 0..1CodeableConceptLanguage of the text
Language (Preferred but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementPatient insurance information
.... sequence 1..1positiveIntInsurance instance identifier
.... focal 1..1booleanCoverage to be used for adjudication
.... coverage 1..1Reference(Coverage)Информация по страховке
.... businessArrangement 0..1stringAdditional provider contract number
.... claimResponse 0..1Reference(ClaimResponse)Результаты вынесения решения
... error 0..*BackboneElementОшибки обработки
.... itemSequence 0..1positiveIntПорядковый номер пункта
.... detailSequence 0..1positiveIntПодробный порядковый номер
.... subDetailSequence 0..1positiveIntСведения о порядковом номере
.... code 1..1CodeableConceptКод ошибки, подробно описывающий проблемы обработки
AdjudicationError (Example)

doco Документация по этому формату

UML-диаграмма (Legend)

ClaimResponse (DomainResource)A unique identifier assigned to this claim responseidentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [1..1] « A code specifying the state of the resource instance. (Strength=Required)FinancialResourceStatusCodes! »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicetype : CodeableConcept [1..1] « The type or discipline-style of the claim. (Strength=Extensible)ClaimTypeCodes+ »A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty servicesubType : CodeableConcept [0..1] « A more granular claim typecode. (Strength=Example)ExampleClaimSubTypeCodes?? »A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the futureuse : code [1..1] « Claim, preauthorization, predetermination. (Strength=Required)Use! »The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimburement is soughtpatient : Reference [1..1] « Patient »The date this resource was createdcreated : dateTime [1..1]The party responsible for authorization, adjudication and reimbursementinsurer : Reference [1..1] « Organization »The provider which is responsible for the claim, predetermination or preauthorizationrequestor : Reference [0..1] « Practitioner|PractitionerRole| Organization »Original request resource referencerequest : Reference [0..1] « Claim »The outcome of the claim, predetermination, or preauthorization processingoutcome : code [1..1] « The result of the claim processing. (Strength=Required)ClaimProcessingCodes! »A human readable description of the status of the adjudicationdisposition : string [0..1]Reference from the Insurer which is used in later communications which refers to this adjudicationpreAuthRef : string [0..1]The time frame during which this authorization is effectivepreAuthPeriod : Period [0..1]Type of Сторона, которой должно быть выплачено возмещение: подписчик, поставщик, другаяpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whomfundsReserve : CodeableConcept [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »A code for Форма, которую необходимо использовать для печати данного содержимогоformCode : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »The actual form, by reference or inclusion, for printing the content or an EOBform : Attachment [0..1]Request for additional supporting or authorizing informationcommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA number to uniquely reference the claim item entriesitemSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AdjudicationA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « Коды вынесенного решения. (Strength=Example)AdjudicationValueCodes?? »A code supporting the understanding of the adjudication result and explaining variance from expected amountreason : CodeableConcept [0..1] « Коды обоснования вынесенного решения. (Strength=Example)AdjudicationReasonCodes?? »Monetary amount associated with the categoryamount : Money [0..1]A non-monetary value associated with the category. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA number to uniquely reference the claim detail entrydetailSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]SubDetailA number to uniquely reference the claim sub-detail entrysubDetailSequence : positiveInt [1..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemClaim items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the details within the claim item which this line is intended to replacedetailSequence : positiveInt [0..*]The sequence number of the sub-details woithin the details within the claim item which this line is intended to replacesubdetailSequence : positiveInt [0..*]The providers who are authorized for the services rendered to the patientprovider : Reference [0..*] « Practitioner|PractitionerRole| Organization »When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »Identifies the program under which this may be recoveredprogramCode : CodeableConcept [0..*] « Program specific reason codes. (Strength=Example)ExampleProgramReasonCodes?? »The date or dates when the service or product was supplied, performed or completedserviced[x] : Type [0..1] « date|Period »Where the product or service was providedlocation[x] : Type [0..1] « CodeableConcept|Address|Reference( Location); Place of service: pharmacy, school, prison, etc. (Strength=Example)ExampleServicePlaceCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]Physical service site on the patient (limb, tooth, etc.)bodySite : CodeableConcept [0..1] « The code for the teeth, quadrant, sextant and arch. (Strength=Example)OralSiteCodes?? »A region or surface of the bodySite, e.g. limb region or tooth surface(s)subSite : CodeableConcept [0..*] « The code for the tooth surface and surface combinations. (Strength=Example)SurfaceCodes?? »The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]AddedItemSubDetailWhen the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the itemproductOrService : CodeableConcept [1..1] « Коды допустимых услуг и продуктов. (Strength=Example)USCLSCodes?? »Item typification or modifiers codes to convey additional context for the product or servicemodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)ModifierTypeCodes?? »The number of repetitions of a service or productquantity : Quantity(SimpleQuantity) [0..1]If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the groupunitPrice : Money [0..1]A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amountfactor : decimal [0..1]The quantity times the unit price for an additional service or product or chargenet : Money [0..1]The numbers associated with notes below which apply to the adjudication of this itemnoteNumber : positiveInt [0..*]TotalA code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is resonsible for in-aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this itemcategory : CodeableConcept [1..1] « Коды вынесенного решения. (Strength=Example)AdjudicationValueCodes?? »Monetary total amount associated with the categoryamount : Money [1..1]PaymentWhether this represents partial or complete payment of the benefits payabletype : CodeableConcept [1..1] « The type (partial, complete) of the payment. (Strength=Example)ExamplePaymentTypeCodes?? »Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudicationadjustment : Money [0..1]Причина корректировки платежаadjustmentReason : CodeableConcept [0..1] « Коды обоснования вынесенного решения по платежам. (Strength=Example) PaymentAdjustmentReasonCodes?? »Estimated date the payment will be issued or the actual issue date of paymentdate : date [0..1]Benefits Сумма, подлежащая оплате, меньшая, чем любая корректировка оплатыamount : Money [1..1]Issuer's unique identifier for the payment instrumentidentifier : Identifier [0..1]NoteA number to uniquely identify a note entrynumber : positiveInt [0..1]The business purpose of the Текст примечанияtype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The explanation or description associated with the processingtext : string [1..1]A code to define the language used in the text of the notelanguage : CodeableConcept [0..1] « Естественный язык. (Strength=Preferred)Common Languages? »InsuranceA number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit ordersequence : positiveInt [1..1]A flag to indicate that this Coverage is to be used for adjudication of this claim when set to truefocal : boolean [1..1]Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information systemcoverage : Reference [1..1] « Coverage »A Деловое соглашениеnumber established between the provider and the insurer for special business processing purposesbusinessArrangement : string [0..1]The result of the adjudication of the line items for the Coverage specified in this insuranceclaimResponse : Reference [0..1] « ClaimResponse »ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structureitemSequence : positiveInt [0..1]The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structuredetailSequence : positiveInt [0..1]The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structuresubDetailSequence : positiveInt [0..1]An error code, from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « Коды ошибок в процессе вынесения решения. (Strength=Example)Adjudication Error ?? »If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this itemadjudication[1..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[0..*]A sub-detail adjudication of a simple product or servicesubDetail[0..*]A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple itemsdetail[0..*]A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-detailsitem[0..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[1..*]The adjudication resultsadjudication[1..*]The third-tier service adjudications for payor added servicessubDetail[0..*]The second-tier service adjudications for payor added servicesdetail[0..*]The first-tier service adjudications for payor added product or service linesaddItem[0..*]The adjudication results which are presented at the header level rather than at the line-item or add-item levelsadjudication[0..*]Categorized monetary totals for the adjudicationtotal[0..*]Payment details for the adjudication of the claimpayment[0..1]A note that describes or explains adjudication results in a human readable formprocessNote[0..*]Financial instruments for reimbursement for the health care products and services specified on the claiminsurance[0..*]Errors encountered during the processing of the adjudicationerror[0..*]

XML-шаблон

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Business Identifier for a claim response --></identifier>
 <status value="[code]"/><!-- 1..1 active | cancelled | draft | entered-in-error -->
 <type><!-- 1..1 CodeableConcept More granular claim type --></type>
 <subType><!-- 0..1 CodeableConcept More granular claim type --></subType>
 <use value="[code]"/><!-- 1..1 claim | preauthorization | predetermination -->
 <patient><!-- 1..1 Reference(Patient) The recipient of the products and services --></patient>
 <created value="[dateTime]"/><!-- 1..1 Response Дата создания -->
 <insurer><!-- 1..1 Reference(Organization) Party responsible for reimbursement --></insurer>
 <requestor><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Party responsible for the claim --></requestor>
 <request><!-- 0..1 Reference(Claim) Идентификатор ресурса, инициировавшего решение по иску --></request>
 <outcome value="[code]"/><!-- 1..1 queued | complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Сообщение о возможности воспользоваться -->
 <preAuthRef value="[string]"/><!-- 0..1 Preauthorization reference -->
 <preAuthPeriod><!-- 0..1 Period Preauthorization reference effective period --></preAuthPeriod>
 <payeeType><!-- 0..1 CodeableConcept Сторона, которой необходимо выплатить все подлежащие оплате выгоды --></payeeType>
 <item>  <!-- 0..* Adjudication for claim line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Claim item instance identifier -->
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication>  <!-- 1..* Детали вынесения решения -->
   <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of adjudication outcome --></reason>
   <amount><!-- 0..1 Money Денежная сумма --></amount>
   <value value="[decimal]"/><!-- 0..1 Неденежное значение -->
  </adjudication>
  <detail>  <!-- 0..* Adjudication for claim details -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Claim detail instance identifier -->
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Adjudication for claim sub-details -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Claim sub-detail instance identifier -->
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Товарные позиции, добавленные страховой компанией -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Порядковый номер пункта -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Подробный порядковый номер -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Сведения о порядковом номере -->
  <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider>
  <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <programCode><!-- 0..* CodeableConcept Program the product or service is provided under --></programCode>
  <serviced[x]><!-- 0..1 date|Period Date or dates of service or product delivery --></serviced[x]>
  <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service or where product was supplied --></location[x]>
  <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
  <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
  <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
  <net><!-- 0..1 Money Total item cost --></net>
  <bodySite><!-- 0..1 CodeableConcept Anatomical location --></bodySite>
  <subSite><!-- 0..* CodeableConcept Anatomical sub-location --></subSite>
  <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
  <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Вынесенное решение по добавленным пунктам --></adjudication>
  <detail>  <!-- 0..* Insurer added line details -->
   <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
   <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
   <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
   <net><!-- 0..1 Money Total item cost --></net>
   <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
   <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Судебное решение по добавленным пунктам --></adjudication>
   <subDetail>  <!-- 0..* Товарные позиции, добавленные страховой компанией -->
    <productOrService><!-- 1..1 CodeableConcept Billing, service, product, or drug code --></productOrService>
    <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
    <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of products or services --></quantity>
    <unitPrice><!-- 0..1 Money Fee, charge or cost per item --></unitPrice>
    <factor value="[decimal]"/><!-- 0..1 Price scaling factor -->
    <net><!-- 0..1 Money Total item cost --></net>
    <noteNumber value="[positiveInt]"/><!-- 0..* Applicable note numbers -->
    <adjudication><!-- 1..* Content as for ClaimResponse.item.adjudication Судебное решение по добавленным пунктам --></adjudication>
   </subDetail>
  </detail>
 </addItem>
 <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Header-level adjudication --></adjudication>
 <total>  <!-- 0..* Adjudication totals -->
  <category><!-- 1..1 CodeableConcept Type of adjudication information --></category>
  <amount><!-- 1..1 Money Financial total for the category --></amount>
 </total>
 <payment>  <!-- 0..1 Payment Details -->
  <type><!-- 1..1 CodeableConcept Partial or complete payment --></type>
  <adjustment><!-- 0..1 Money Согласование платежей по не связанным с иском вопросам --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected date of payment -->
  <amount><!-- 1..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Business identifier for the payment --></identifier>
 </payment>
 <fundsReserve><!-- 0..1 CodeableConcept Статус зарезервированных денежных средств --></fundsReserve>
 <formCode><!-- 0..1 CodeableConcept Идентификатор формы, которую необходимо использовать для печати --></formCode>
 <form><!-- 0..1 Attachment Printed reference or actual form --></form>
 <processNote>  <!-- 0..* Note concerning adjudication -->
  <number value="[positiveInt]"/><!-- 0..1 Note instance identifier -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 1..1 Пояснительный текст примечания -->
  <language><!-- 0..1 CodeableConcept Language of the text --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Patient insurance information -->
  <sequence value="[positiveInt]"/><!-- 1..1 Insurance instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Coverage to be used for adjudication -->
  <coverage><!-- 1..1 Reference(Coverage) Информация по страховке --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Additional provider contract number -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Результаты вынесения решения --></claimResponse>
 </insurance>
 <error>  <!-- 0..* Ошибки обработки -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Порядковый номер пункта -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Подробный порядковый номер -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Сведения о порядковом номере -->
  <code><!-- 1..1 CodeableConcept Код ошибки, подробно описывающий проблемы обработки --></code>
 </error>
</ClaimResponse>

JSON-шаблон

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Business Identifier for a claim response
  "status" : "<code>", // R!  active | cancelled | draft | entered-in-error
  "type" : { CodeableConcept }, // R!  More granular claim type
  "subType" : { CodeableConcept }, // More granular claim type
  "use" : "<code>", // R!  claim | preauthorization | predetermination
  "patient" : { Reference(Patient) }, // R!  The recipient of the products and services
  "created" : "<dateTime>", // R!  Response Дата создания
  "insurer" : { Reference(Organization) }, // R!  Party responsible for reimbursement
  "requestor" : { Reference(Practitioner|PractitionerRole|Organization) }, // Party responsible for the claim
  "request" : { Reference(Claim) }, // Идентификатор ресурса, инициировавшего решение по иску
  "outcome" : "<code>", // R!  queued | complete | error | partial
  "disposition" : "<string>", // Сообщение о возможности воспользоваться
  "preAuthRef" : "<string>", // Preauthorization reference
  "preAuthPeriod" : { Period }, // Preauthorization reference effective period
  "payeeType" : { CodeableConcept }, // Сторона, которой необходимо выплатить все подлежащие оплате выгоды
  "item" : [{ // Adjudication for claim line items
    "itemSequence" : "<positiveInt>", // R!  Claim item instance identifier
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ // R!  Детали вынесения решения
      "category" : { CodeableConcept }, // R!  Type of adjudication information
      "reason" : { CodeableConcept }, // Explanation of adjudication outcome
      "amount" : { Money }, // Денежная сумма
      "value" : <decimal> // Неденежное значение
    }],
    "detail" : [{ // Adjudication for claim details
      "detailSequence" : "<positiveInt>", // R!  Claim detail instance identifier
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Detail level adjudication details
      "subDetail" : [{ // Adjudication for claim sub-details
        "subDetailSequence" : "<positiveInt>", // R!  Claim sub-detail instance identifier
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Товарные позиции, добавленные страховой компанией
    "itemSequence" : ["<positiveInt>"], // Порядковый номер пункта
    "detailSequence" : ["<positiveInt>"], // Подробный порядковый номер
    "subdetailSequence" : ["<positiveInt>"], // Сведения о порядковом номере
    "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers
    "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "programCode" : [{ CodeableConcept }], // Program the product or service is provided under
    // serviced[x]: Date or dates of service or product delivery. One of these 2:
    "servicedDate" : "<date>",
    "servicedPeriod" : { Period },
    // location[x]: Place of service or where product was supplied. One of these 3:
    "locationCodeableConcept" : { CodeableConcept },
    "locationAddress" : { Address },
    "locationReference" : { Reference(Location) },
    "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
    "unitPrice" : { Money }, // Fee, charge or cost per item
    "factor" : <decimal>, // Price scaling factor
    "net" : { Money }, // Total item cost
    "bodySite" : { CodeableConcept }, // Anatomical location
    "subSite" : [{ CodeableConcept }], // Anatomical sub-location
    "noteNumber" : ["<positiveInt>"], // Applicable note numbers
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Вынесенное решение по добавленным пунктам
    "detail" : [{ // Insurer added line details
      "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
      "unitPrice" : { Money }, // Fee, charge or cost per item
      "factor" : <decimal>, // Price scaling factor
      "net" : { Money }, // Total item cost
      "noteNumber" : ["<positiveInt>"], // Applicable note numbers
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // R!  Судебное решение по добавленным пунктам
      "subDetail" : [{ // Товарные позиции, добавленные страховой компанией
        "productOrService" : { CodeableConcept }, // R!  Billing, service, product, or drug code
        "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
        "quantity" : { Quantity(SimpleQuantity) }, // Count of products or services
        "unitPrice" : { Money }, // Fee, charge or cost per item
        "factor" : <decimal>, // Price scaling factor
        "net" : { Money }, // Total item cost
        "noteNumber" : ["<positiveInt>"], // Applicable note numbers
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // R!  Судебное решение по добавленным пунктам
      }]
    }]
  }],
  "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Header-level adjudication
  "total" : [{ // Adjudication totals
    "category" : { CodeableConcept }, // R!  Type of adjudication information
    "amount" : { Money } // R!  Financial total for the category
  }],
  "payment" : { // Payment Details
    "type" : { CodeableConcept }, // R!  Partial or complete payment
    "adjustment" : { Money }, // Согласование платежей по не связанным с иском вопросам
    "adjustmentReason" : { CodeableConcept }, // Explanation for the adjustment
    "date" : "<date>", // Expected date of payment
    "amount" : { Money }, // R!  Payable amount after adjustment
    "identifier" : { Identifier } // Business identifier for the payment
  },
  "fundsReserve" : { CodeableConcept }, // Статус зарезервированных денежных средств
  "formCode" : { CodeableConcept }, // Идентификатор формы, которую необходимо использовать для печати
  "form" : { Attachment }, // Printed reference or actual form
  "processNote" : [{ // Note concerning adjudication
    "number" : "<positiveInt>", // Note instance identifier
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // R!  Пояснительный текст примечания
    "language" : { CodeableConcept } // Language of the text
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Patient insurance information
    "sequence" : "<positiveInt>", // R!  Insurance instance identifier
    "focal" : <boolean>, // R!  Coverage to be used for adjudication
    "coverage" : { Reference(Coverage) }, // R!  Информация по страховке
    "businessArrangement" : "<string>", // Additional provider contract number
    "claimResponse" : { Reference(ClaimResponse) } // Результаты вынесения решения
  }],
  "error" : [{ // Ошибки обработки
    "itemSequence" : "<positiveInt>", // Порядковый номер пункта
    "detailSequence" : "<positiveInt>", // Подробный порядковый номер
    "subDetailSequence" : "<positiveInt>", // Сведения о порядковом номере
    "code" : { CodeableConcept } // R!  Код ошибки, подробно описывающий проблемы обработки
  }]
}

Turtle-шаблон

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Business Identifier for a claim response
  fhir:ClaimResponse.status [ code ]; # 1..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.type [ CodeableConcept ]; # 1..1 More granular claim type
  fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 More granular claim type
  fhir:ClaimResponse.use [ code ]; # 1..1 claim | preauthorization | predetermination
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 1..1 The recipient of the products and services
  fhir:ClaimResponse.created [ dateTime ]; # 1..1 Response Дата создания
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 1..1 Party responsible for reimbursement
  fhir:ClaimResponse.requestor [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Party responsible for the claim
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Идентификатор ресурса, инициировавшего решение по иску
  fhir:ClaimResponse.outcome [ code ]; # 1..1 queued | complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Сообщение о возможности воспользоваться
  fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Preauthorization reference
  fhir:ClaimResponse.preAuthPeriod [ Period ]; # 0..1 Preauthorization reference effective period
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Сторона, которой необходимо выплатить все подлежащие оплате выгоды
  fhir:ClaimResponse.item [ # 0..* Adjudication for claim line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Claim item instance identifier
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.item.adjudication [ # 1..* Детали вынесения решения
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Type of adjudication information
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Денежная сумма
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Неденежное значение
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Adjudication for claim details
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Claim detail instance identifier
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Adjudication for claim sub-details
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Claim sub-detail instance identifier
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Товарные позиции, добавленные страховой компанией
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Порядковый номер пункта
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Подробный порядковый номер
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Сведения о порядковом номере
    fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers
    fhir:ClaimResponse.addItem.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program the product or service is provided under
    # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of service or product delivery. One of these 2
      fhir:ClaimResponse.addItem.servicedDate [ date ]
      fhir:ClaimResponse.addItem.servicedPeriod [ Period ]
    # ClaimResponse.addItem.location[x] : 0..1 Place of service or where product was supplied. One of these 3
      fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ]
      fhir:ClaimResponse.addItem.locationAddress [ Address ]
      fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ]
    fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
    fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
    fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor
    fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost
    fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Anatomical location
    fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Anatomical sub-location
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Вынесенное решение по добавленным пунктам
    fhir:ClaimResponse.addItem.detail [ # 0..* Insurer added line details
      fhir:ClaimResponse.addItem.detail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
      fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
      fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor
      fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Судебное решение по добавленным пунктам
      fhir:ClaimResponse.addItem.detail.subDetail [ # 0..* Товарные позиции, добавленные страховой компанией
        fhir:ClaimResponse.addItem.detail.subDetail.productOrService [ CodeableConcept ]; # 1..1 Billing, service, product, or drug code
        fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
        fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of products or services
        fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per item
        fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor
        fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost
        fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* Applicable note numbers
        fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 1..* Судебное решение по добавленным пунктам
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Header-level adjudication
  fhir:ClaimResponse.total [ # 0..* Adjudication totals
    fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Type of adjudication information
    fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Financial total for the category
  ], ...;
  fhir:ClaimResponse.payment [ # 0..1 Payment Details
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 1..1 Partial or complete payment
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Согласование платежей по не связанным с иском вопросам
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected date of payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 1..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Business identifier for the payment
  ];
  fhir:ClaimResponse.fundsReserve [ CodeableConcept ]; # 0..1 Статус зарезервированных денежных средств
  fhir:ClaimResponse.formCode [ CodeableConcept ]; # 0..1 Идентификатор формы, которую необходимо использовать для печати
  fhir:ClaimResponse.form [ Attachment ]; # 0..1 Printed reference or actual form
  fhir:ClaimResponse.processNote [ # 0..* Note concerning adjudication
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Note instance identifier
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 1..1 Пояснительный текст примечания
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language of the text
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Patient insurance information
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Insurance instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Coverage to be used for adjudication
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Информация по страховке
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Additional provider contract number
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Результаты вынесения решения
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Ошибки обработки
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Порядковый номер пункта
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Подробный порядковый номер
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Сведения о порядковом номере
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Код ошибки, подробно описывающий проблемы обработки
  ], ...;
]

Changes since Release 3

ClaimResponse
ClaimResponse.status
  • Min Cardinality changed from 0 to 1
ClaimResponse.type
  • Added Mandatory Element
ClaimResponse.subType
  • Added Element
ClaimResponse.use
  • Added Mandatory Element
ClaimResponse.patient
  • Min Cardinality changed from 0 to 1
ClaimResponse.created
  • Min Cardinality changed from 0 to 1
ClaimResponse.insurer
  • Min Cardinality changed from 0 to 1
ClaimResponse.requestor
  • Added Element
ClaimResponse.outcome
  • Min Cardinality changed from 0 to 1
  • Type changed from CodeableConcept to code
  • Add Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.preAuthRef
  • Added Element
ClaimResponse.preAuthPeriod
  • Added Element
ClaimResponse.item.itemSequence
  • Added Mandatory Element
ClaimResponse.item.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.item.detail.detailSequence
  • Added Mandatory Element
ClaimResponse.item.detail.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Mandatory Element
ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.provider
  • Added Element
ClaimResponse.addItem.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.programCode
  • Added Element
ClaimResponse.addItem.serviced[x]
  • Added Element
ClaimResponse.addItem.location[x]
  • Added Element
ClaimResponse.addItem.quantity
  • Added Element
ClaimResponse.addItem.unitPrice
  • Added Element
ClaimResponse.addItem.factor
  • Added Element
ClaimResponse.addItem.net
  • Added Element
ClaimResponse.addItem.bodySite
  • Added Element
ClaimResponse.addItem.subSite
  • Added Element
ClaimResponse.addItem.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.addItem.detail.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.detail.quantity
  • Added Element
ClaimResponse.addItem.detail.unitPrice
  • Added Element
ClaimResponse.addItem.detail.factor
  • Added Element
ClaimResponse.addItem.detail.net
  • Added Element
ClaimResponse.addItem.detail.adjudication
  • Min Cardinality changed from 0 to 1
ClaimResponse.addItem.detail.subDetail
  • Added Element
ClaimResponse.addItem.detail.subDetail.productOrService
  • Added Mandatory Element
ClaimResponse.addItem.detail.subDetail.modifier
  • Added Element
ClaimResponse.addItem.detail.subDetail.quantity
  • Added Element
ClaimResponse.addItem.detail.subDetail.unitPrice
  • Added Element
ClaimResponse.addItem.detail.subDetail.factor
  • Added Element
ClaimResponse.addItem.detail.subDetail.net
  • Added Element
ClaimResponse.addItem.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.addItem.detail.subDetail.adjudication
  • Added Mandatory Element
ClaimResponse.adjudication
  • Added Element
ClaimResponse.total
  • Added Element
ClaimResponse.total.category
  • Added Mandatory Element
ClaimResponse.total.amount
  • Added Mandatory Element
ClaimResponse.payment.type
  • Min Cardinality changed from 0 to 1
ClaimResponse.payment.amount
  • Min Cardinality changed from 0 to 1
ClaimResponse.fundsReserve
  • Added Element
ClaimResponse.formCode
  • Added Element
ClaimResponse.form
  • Type changed from CodeableConcept to Attachment
ClaimResponse.processNote.type
  • Type changed from CodeableConcept to code
ClaimResponse.processNote.text
  • Min Cardinality changed from 0 to 1
ClaimResponse.processNote.language
  • Change binding strength from extensible to preferred
ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.requestProvider
  • deleted
ClaimResponse.requestOrganization
  • deleted
ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.addItem.revenue
  • deleted
ClaimResponse.addItem.category
  • deleted
ClaimResponse.addItem.service
  • deleted
ClaimResponse.addItem.fee
  • deleted
ClaimResponse.addItem.detail.revenue
  • deleted
ClaimResponse.addItem.detail.category
  • deleted
ClaimResponse.addItem.detail.service
  • deleted
ClaimResponse.addItem.detail.fee
  • deleted
ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.totalCost
  • deleted
ClaimResponse.unallocDeductable
  • deleted
ClaimResponse.totalBenefit
  • deleted
ClaimResponse.reserved
  • deleted
ClaimResponse.insurance.preAuthRef
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)

 

See the Profiles & Extensions and the Альтернативные определения: Основное определение XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the Анализ зависимостей

PathОписаниеТипСсылка
ClaimResponse.status A code specifying the state of the resource instance.RequiredFinancialResourceStatusCodes
ClaimResponse.type The type or discipline-style of the claim.ExtensibleClaimTypeCodes
ClaimResponse.subType A more granular claim typecode.ExampleExampleClaimSubTypeCodes
ClaimResponse.use Claim, preauthorization, predetermination.RequiredUse
ClaimResponse.outcome The result of the claim processing.RequiredClaimProcessingCodes
ClaimResponse.payeeType A code for the party to be reimbursed.ExampleClaim Payee Type Codes
ClaimResponse.item.adjudication.category
ClaimResponse.total.category
Коды вынесенного решения.ExampleAdjudicationValueCodes
ClaimResponse.item.adjudication.reason Коды обоснования вынесенного решения.ExampleAdjudicationReasonCodes
ClaimResponse.addItem.productOrService
ClaimResponse.addItem.detail.productOrService
ClaimResponse.addItem.detail.subDetail.productOrService
Коды допустимых услуг и продуктов.ExampleUSCLSCodes
ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.modifier
ClaimResponse.addItem.detail.subDetail.modifier
Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifierTypeCodes
ClaimResponse.addItem.programCode Program specific reason codes.ExampleExampleProgramReasonCodes
ClaimResponse.addItem.location[x] Place of service: pharmacy, school, prison, etc.ExampleExampleServicePlaceCodes
ClaimResponse.addItem.bodySite The code for the teeth, quadrant, sextant and arch.ExampleOralSiteCodes
ClaimResponse.addItem.subSite The code for the tooth surface and surface combinations.ExampleSurfaceCodes
ClaimResponse.payment.type The type (partial, complete) of the payment.ExampleExamplePaymentTypeCodes
ClaimResponse.payment.adjustmentReason Коды обоснования вынесенного решения по платежам.ExamplePaymentAdjustmentReasonCodes
ClaimResponse.fundsReserve For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
ClaimResponse.formCode The forms codes.ExampleForm Codes
ClaimResponse.processNote.type The presentation types of notes.RequiredNoteType
ClaimResponse.processNote.language Естественный язык.Preferred, but limited to All LanguagesCommon Languages
ClaimResponse.error.code Коды ошибок в процессе вынесения решения.ExampleAdjudication Error Codes

Параметры поиска для этого ресурса. Также к нему применяются общие параметры. Более подробную информацию о поиске в REST, обмене сообщениями и сервисах см. в разделе Поиск.

ИмяТипОпределениеВыражениеIn Common
createddateДата созданияClaimResponse.created
dispositionstringСодержимое постановления по разрешению делаClaimResponse.disposition
identifiertokenThe identity of the ClaimResponseClaimResponse.identifier
insurerreferenceОрганизация, которая создала этот ресурсClaimResponse.insurer
(Organization)
outcometokenРезультаты обработкиClaimResponse.outcome
patientreferenceThe subject of careClaimResponse.patient
(Patient)
payment-datedateThe expected payment dateClaimResponse.payment.date
requestreferenceСсылка на искClaimResponse.request
(Claim)
requestorreferenceThe Provider of the claimClaimResponse.requestor
(Practitioner, Organization, PractitionerRole)
statustokenThe status of the ClaimResponseClaimResponse.status
usetokenThe type of claimClaimResponse.use