Health New Zealand Te Whatu Ora Shared Care FHIR API - Local Development build (v0.4.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: NZ Telehealth Claim Response

A FHIR resource profile for NZ Telehealth Claim Responses for 24/7 telehealth services.

Note: In 4B item.adjudication, item.detail.adjudication, payment.amount, insurer are compulsory fields, but not utilized in the telehealth implementation. item.adjudication.quantity R5 is item.adjudication.value in R4B.

This profile is used to represent telehealth claim responses in New Zealand for 24/7 telehealth services.

Usages:

• Examples for this Profile: ClaimResponse/NzTelehealthClaimResponseExample

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business identifier(s) for the claim response
status	?!Σ	1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Date & time of claim determination
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request	Σ	1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item		1..*	BackboneElement	Claim response items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Claim-level adjudication
total	Σ	0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Summary of the payment being made
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
error		0..*	BackboneElement	Collection of errors produced during claim determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
code		1..1	CodeableConcept	Error code Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClaimResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG
ClaimResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
identifier		1..*	Identifier	Business identifier(s) for the claim response
status		1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error
type		1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
created		1..1	dateTime	Date & time of claim determination
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request		1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
item		1..*	BackboneElement	Claim response items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
adjudication		0..*		Claim-level adjudication
total		0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
payment		0..1	BackboneElement	Summary of the payment being made
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
error		0..*	BackboneElement	Collection of errors produced during claim determination
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
code		1..1	CodeableConcept	Error code
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business identifier(s) for the claim response
status	?!Σ	1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Date & time of claim determination
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request	Σ	1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		1..*	BackboneElement	Claim response items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Claim-level adjudication
total	Σ	0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Summary of the payment being made
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Collection of errors produced during claim determination
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

• NZ Telehealth Claim (https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/SharedCareClaim)

Extensions

This structure refers to these extensions:

• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business identifier(s) for the claim response
status	?!Σ	1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Date & time of claim determination
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request	Σ	1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item		1..*	BackboneElement	Claim response items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Claim-level adjudication
total	Σ	0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Summary of the payment being made
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
error		0..*	BackboneElement	Collection of errors produced during claim determination
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
code		1..1	CodeableConcept	Error code Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClaimResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG
ClaimResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
identifier		1..*	Identifier	Business identifier(s) for the claim response
status		1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error
type		1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
created		1..1	dateTime	Date & time of claim determination
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request		1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
item		1..*	BackboneElement	Claim response items
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
adjudication		0..*		Claim-level adjudication
total		0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
payment		0..1	BackboneElement	Summary of the payment being made
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
error		0..*	BackboneElement	Collection of errors produced during claim determination
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
code		1..1	CodeableConcept	Error code
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse		0..*	ClaimResponse	Response to a claim predetermination or preauthorization
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier		1..*	Identifier	Business identifier(s) for the claim response
status	?!Σ	1..1	code	Status of the Claim Response: active, cancelled, draft, entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
type	Σ	1..1	CodeableConcept	More granular claim type Binding: NZ Claim Types (extensible)
subType		0..1	CodeableConcept	More granular claim type Binding: NZ Claim Subtypes (extensible)
use	Σ	1..1	code	claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination.
patient	Σ	1..1	Reference(Patient)	The recipient of the products and services
created	Σ	1..1	dateTime	Date & time of claim determination
insurer	Σ	1..1	Reference(Organization)	Party responsible for reimbursement
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the Claim
request	Σ	1..1	Reference(NZ Telehealth Claim)	Reference to the Claim that was determined
outcome	Σ	1..1	code	queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition		0..1	string	Disposition Message
preAuthRef		0..1	string	Preauthorization reference
preAuthPeriod		0..1	Period	Preauthorization reference effective period
payeeType		0..1	CodeableConcept	Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item		1..*	BackboneElement	Claim response items
id		0..1	string	Unique id for inter-element referencing
Slices for extension		1..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:productOrService		1..1	CodeableConcept	Product Or Service URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		1..1	positiveInt	Value of the corresponding Claim.item.sequence
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	BackboneElement	Adjudication (reason, amount, quantity) for each Adjudication Value Code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category		1..1	CodeableConcept	Codified representation of adjudication outcome Binding: Adjudication Value Codes (extensible)
reason		0..1	CodeableConcept	Codified reason(s) for the adjudication Binding: Adjudication Reason Codes (extensible)
amount		1..1	Money	Monetary value of the adjudication
value		0..1	decimal	Non-monetary value of the adjudication
detail		0..*	BackboneElement	Any sub-determinations of this itemSequence
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:traceNumber		0..*	Identifier	Trace Number URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
extension:reviewOutcome		0..1	(Complex)	Review Outcome URL: https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detailSequence		1..1	positiveInt	Value of the corresponding Claim.item.detail.sequence
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Detail level adjudication details
subDetail		0..*	BackboneElement	Adjudication for claim sub-details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
subDetailSequence		1..1	positiveInt	Claim sub-detail instance identifier
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		0..*	See adjudication (ClaimResponse)	Subdetail level adjudication details
addItem		0..*	BackboneElement	Any line items added by Health NZ to the claim determination that were not in the original claim
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..*	positiveInt	Item sequence number
detailSequence		0..*	positiveInt	Detail sequence number
subdetailSequence		0..*	positiveInt	Subdetail sequence number
provider		0..*	Reference(Practitioner | PractitionerRole | Organization)	Authorized providers
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode		0..*	CodeableConcept	Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x]		0..1		Date or dates of service or product delivery
servicedDate			date
servicedPeriod			Period
location[x]		0..1		Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept			CodeableConcept
locationAddress			Address
locationReference			Reference(Location)
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
bodySite		0..1	CodeableConcept	Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite		0..*	CodeableConcept	Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items adjudication
detail		0..*	BackboneElement	Insurer added line details
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
subDetail		0..*	BackboneElement	Insurer added line items
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
productOrService		1..1	CodeableConcept	Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier		0..*	CodeableConcept	Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity		0..1	SimpleQuantity	Count of products or services
unitPrice		0..1	Money	Fee, charge or cost per item
factor		0..1	decimal	Price scaling factor
net		0..1	Money	Total item cost
noteNumber		0..*	positiveInt	Applicable note numbers
adjudication		1..*	See adjudication (ClaimResponse)	Added items detail adjudication
adjudication		0..*	See adjudication (ClaimResponse)	Claim-level adjudication
total	Σ	0..*	BackboneElement	Financial total of the claim for each Adjudication Value Code
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	Σ	1..1	CodeableConcept	Type of adjudication information Binding: AdjudicationValueCodes (example): The adjudication codes.
amount	Σ	1..1	Money	Financial total for the category
payment		0..1	BackboneElement	Summary of the payment being made
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
type		1..1	CodeableConcept	Payment Type Code = complete or partial Binding: Payment Type Codes (extensible)
adjustment		0..1	Money	Payment adjustment for non-claim issues
adjustmentReason		0..1	CodeableConcept	Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date		0..1	date	Expected date of payment (if known)
amount		1..1	Money	Payment amount
identifier		0..1	Identifier	Business identifier for the payment
fundsReserve		0..1	CodeableConcept	Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode		0..1	CodeableConcept	Printed form identifier Binding: Form Codes (example): The forms codes.
form		0..1	Attachment	Printed reference or actual form
processNote		0..*	BackboneElement	Note concerning adjudication
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
number		0..1	positiveInt	Note instance identifier
type		0..1	code	display | print | printoper Binding: NoteType (required): The presentation types of notes.
text		1..1	string	Note explanatory text
language		0..1	CodeableConcept	Language of the text Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error		0..*	BackboneElement	Collection of errors produced during claim determination
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence		0..1	positiveInt	Refers to itemSequence to which the error relates
detailSequence		0..1	positiveInt	Refers to detailSequence to which the error relates
subDetailSequence		0..1	positiveInt	Subdetail sequence number
code		1..1	CodeableConcept	Error code Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
ClaimResponse.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.status	required	FinancialResourceStatusCodes http://hl7.org/fhir/ValueSet/fm-status|4.0.1 From the FHIR Standard
ClaimResponse.type	extensible	NzClaimTypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-type) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-types From this IG
ClaimResponse.subType	extensible	NzClaimSubtypes(a valid code from https://standards.digital.health.nz/ns/nz-claim-subtype) https://fhir-ig.digital.health.nz/shared-care/ValueSet/nz-claim-subtypes From this IG
ClaimResponse.use	required	Use http://hl7.org/fhir/ValueSet/claim-use|4.0.1 From the FHIR Standard
ClaimResponse.outcome	required	ClaimProcessingCodes http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1 From the FHIR Standard
ClaimResponse.payeeType	example	Claim Payee Type Codes http://hl7.org/fhir/ValueSet/payeetype From the FHIR Standard
ClaimResponse.item.adjudication.category	extensible	AdjudicationValueCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-value-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-value-codes From this IG
ClaimResponse.item.adjudication.reason	extensible	AdjudicationReasonCodes(a valid code from https://standards.digital.health.nz/ns/adjudication-reason-code) https://fhir-ig.digital.health.nz/shared-care/ValueSet/adjudication-reason-codes From this IG
ClaimResponse.addItem.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.programCode	example	ExampleProgramReasonCodes http://hl7.org/fhir/ValueSet/ex-program-code From the FHIR Standard
ClaimResponse.addItem.location[x]	example	ExampleServicePlaceCodes http://hl7.org/fhir/ValueSet/service-place From the FHIR Standard
ClaimResponse.addItem.bodySite	example	OralSiteCodes http://hl7.org/fhir/ValueSet/tooth From the FHIR Standard
ClaimResponse.addItem.subSite	example	SurfaceCodes http://hl7.org/fhir/ValueSet/surface From the FHIR Standard
ClaimResponse.addItem.detail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService	example	USCLSCodes http://hl7.org/fhir/ValueSet/service-uscls From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier	example	ModifierTypeCodes http://hl7.org/fhir/ValueSet/claim-modifiers From the FHIR Standard
ClaimResponse.total.category	example	AdjudicationValueCodes http://hl7.org/fhir/ValueSet/adjudication From the FHIR Standard
ClaimResponse.payment.type	extensible	PaymentTypeCodes https://fhir-ig.digital.health.nz/shared-care/ValueSet/payment-type-codes From this IG
ClaimResponse.payment.adjustmentReason	example	PaymentAdjustmentReasonCodes http://hl7.org/fhir/ValueSet/payment-adjustment-reason From the FHIR Standard
ClaimResponse.fundsReserve	example	Funds Reservation Codes http://hl7.org/fhir/ValueSet/fundsreserve From the FHIR Standard
ClaimResponse.formCode	example	Form Codes http://hl7.org/fhir/ValueSet/forms From the FHIR Standard
ClaimResponse.processNote.type	required	NoteType http://hl7.org/fhir/ValueSet/note-type|4.0.1 From the FHIR Standard
ClaimResponse.processNote.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
ClaimResponse.error.code	example	Adjudication Error Codes http://hl7.org/fhir/ValueSet/adjudication-error From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	ClaimResponse	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	ClaimResponse	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	ClaimResponse	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	ClaimResponse	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from ClaimResponse

Summary

Mandatory: 6 elements

Structures

This structure refers to these other structures:

• NZ Telehealth Claim (https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/SharedCareClaim)

Extensions

This structure refers to these extensions:

• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/trace-number
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/product-or-service
• https://fhir-ig.digital.health.nz/shared-care/StructureDefinition/review-outcome