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Resource Profile: Resposta Guia OCI

Official URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RespostaGuiaOCIBRIPES Version: 0.1.0
Active as of 2025-03-17 Computable Name: RespostaGuiaOCIBRIPES

Perfil para resposta de guias de autorização no projeto Ecoinfo, baseado no recurso ClaimResponse.

Introdução

O recurso ClaimResponse no contexto OCI/APAC foi projetado para capturar as respostas às solicitações de autorização e reembolso de procedimentos médicos e exames ambulatoriais de alta complexidade no âmbito do SUS usando o instrumento APAC (Autorização de Procedimentos de Alta Complexidade). Este recurso segue as especificações HL7 FHIR R4 e foi adaptado para atender às necessidades do Sistema Único de Saúde (SUS) no Brasil, considerando as particularidades do processo da APAC.

Objetivo

Fornecer uma estrutura padronizada para documentar e comunicar os resultados das solicitações de procedimentos realizados sob o sistema APAC. Este recurso promove a transparência e a interoperabilidade entre sistemas de saúde regionais e nacionais.

Escopo

O ClaimResponse é utilizado para registrar os seguintes aspectos:

  • Status da Solicitação: Indica se a solicitação foi aprovada, rejeitada ou necessita de revisão adicional.
  • Pagamentos: Detalha os valores aprovados, a moeda utilizada e a data do pagamento.
  • Erros: Documenta quaisquer problemas encontrados durante o processamento da solicitação.
  • Notas: Fornece observações adicionais relacionadas à decisão do processamento.

Elementos Chave

Elementos Obrigatórios

  • Identificador: Cada resposta deve incluir um identificador único para rastreabilidade.
  • Resultado: Define o desfecho da solicitação (e.g., "complete", "error", "partial").
  • Pagamento: Informações sobre o valor, tipo e data do pagamento.
  • Erros: Códigos e descrições detalhadas de erros encontrados, quando aplicável.

Elementos Must Support

  • Disposição: Uma descrição legível detalhando o motivo do desfecho da solicitação.
  • Notas: Explicações adicionais fornecidas pelo sistema ou revisores humanos.
  • Cobertura: Confirmação do plano de saúde (ex.: SUS).

Limites e Relacionamentos

  • Cada ClaimResponse deve estar diretamente relacionado a um Claim, garantindo rastreabilidade e consistência.
  • O recurso deve referenciar os mesmos identificadores do recurso Claim correspondente.
  • Deve incluir erros específicos para procedimentos rejeitados ou informações ausentes/inválidas.

Casos de Uso

Uso Principal

Registrar as respostas a solicitações de reembolso ou autorização de procedimentos médicos sob o contexto OCI/APAC.

Exemplos

  • Aprovação parcial para reembolso de procedimentos realizados.
  • Rejeição de uma solicitação devido a erro de código de procedimento ou dados incompletos.

Uso Indevido

  • Respostas duplicadas para o mesmo identificador de solicitação.
  • Ausência de detalhes críticos, como valor de pagamento ou códigos de erro em caso de rejeição.

Identificadores e Extensões

  • Identificadores: Cada resposta deve conter um identificador único para rastreamento, como o número APAC.
  • Extensões:
    • Detalhes do Pagamento: Inclui informações adicionais, como motivo para pagamento parcial.
    • Códigos de Erro: Detalha erros específicos encontrados no processamento.

Benefícios

  • Transparência: Fornece detalhes claros sobre o status das solicitações.
  • Padronização: Garante uniformidade no registro das respostas às reivindicações.
  • Interoperabilidade: Facilita a troca de informações entre diferentes sistemas regionais e nacionais.
  • Eficiência: Melhora a rastreabilidade e o tempo de resposta para prestadores e pacientes.

Usos:

  • Este Perfil não é utilizado por nenhum perfil neste guia de implementação

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.

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type Σ 1..1 CodeableConcept Tipo de resposta
Vínculo: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept Subtipo de resposta
Vínculo: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use Σ 1..1 code Tipo de uso da resposta
Vínculo: Use (required): Claim, preauthorization, predetermination.
Valor fixo: claim
... patient Σ 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created Σ 1..1 dateTime Data de criação da resposta
... insurer Σ 1..1 Reference(Organization) Ente responsável pela OCI
.... display Σ 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request Σ 1..1 Reference(Claim) Referência ao pedido original
... outcome Σ 1..1 code Resultado do processamento
Vínculo: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Mensagem explicativa do resultado
... item 0..* BackboneElement Itens processados no pedido
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Sequência do item
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Categoria da adjudicação
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
..... amount 0..1 Money Valor da adjudicação
.... detail 0..* BackboneElement Detalhes da adjudicação
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* Ver adjudication (ClaimResponse) detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* Ver adjudication (ClaimResponse) detalhes da adjudicação do subDetail
... payment 0..1 BackboneElement Detalhes do pagamento
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... amount 1..1 Money Valor do pagamento

doco Documentação para este formato

Terminologia Ligações

CaminhoConformidadeValueSet / CódigoURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From a norma FHIR
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
From a norma FHIR
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
From a norma FHIR
ClaimResponse.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From a norma FHIR
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
From a norma FHIR
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html

Restrições

IdGrauCaminho(s)DetalhesRequisitos
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ClaimResponse

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... status 1..1 code Status da resposta
... type 1..1 CodeableConcept Tipo de resposta
.... coding
..... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-type
..... code 0..1 code Symbol in syntax defined by the system
Valor fixo: apac
.... coding
..... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-subtype
..... code 0..1 code Symbol in syntax defined by the system
Vínculo: https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype (required)
... use 1..1 code Tipo de uso da resposta
Valor fixo: claim
... patient 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created 1..1 dateTime Data de criação da resposta
... insurer 1..1 Reference(Organization) Ente responsável pela OCI
.... display 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request 1..1 Reference(Claim) Referência ao pedido original
... outcome 1..1 code Resultado do processamento
... disposition 0..1 string Mensagem explicativa do resultado
... item 0..* BackboneElement Itens processados no pedido
.... itemSequence 1..1 positiveInt Sequência do item
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... category 1..1 CodeableConcept Categoria da adjudicação
..... amount 0..1 Money Valor da adjudicação
.... detail 0..* BackboneElement Detalhes da adjudicação
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... subDetailSequence 1..1 positiveInt Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* detalhes da adjudicação do subDetail
... payment 0..1 BackboneElement Detalhes do pagamento
.... type 1..1 CodeableConcept Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... amount 1..1 Money Valor do pagamento
... error
.... code 1..1 CodeableConcept Código do erro
..... coding
...... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/fhir/CodeSystem/adjudication-error

doco Documentação para este formato

Terminologia Ligações (Diferencial)

CaminhoConformidadeConjunto de valoresURI
ClaimResponse.subType.coding.coderequiredhttps://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html
NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... 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
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... 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
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!Σ 1..1 code Status da resposta
Vínculo: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Tipo de resposta
Vínculo: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-type
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Valor fixo: apac
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subType 0..1 CodeableConcept Subtipo de resposta
Vínculo: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-subtype
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Vínculo: https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype (required)
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... use Σ 1..1 code Tipo de uso da resposta
Vínculo: Use (required): Claim, preauthorization, predetermination.
Valor fixo: claim
... patient Σ 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created Σ 1..1 dateTime Data de criação da resposta
... insurer Σ 1..1 Reference(Organization) Ente responsável pela OCI
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request Σ 1..1 Reference(Claim) Referência ao pedido original
... outcome Σ 1..1 code Resultado do processamento
Vínculo: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Mensagem explicativa do resultado
... 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
Vínculo: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item 0..* BackboneElement Itens processados no pedido
.... 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 1..1 positiveInt Sequência do item
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... 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 Categoria da adjudicação
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Vínculo: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 0..1 Money Valor da adjudicação
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Detalhes da adjudicação
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* Ver adjudication (ClaimResponse) detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... 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 Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* Ver adjudication (ClaimResponse) detalhes da adjudicação do subDetail
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Vínculo: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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
Vínculo: 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
Vínculo: 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
Vínculo: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Vínculo: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* Ver 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
Vínculo: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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..* Ver 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
Vínculo: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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..* Ver adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* Ver adjudication (ClaimResponse) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Detalhes do pagamento
.... 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 Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Vínculo: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 1..1 Money Valor do pagamento
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve 0..1 CodeableConcept Funds reserved status
Vínculo: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 CodeableConcept Printed form identifier
Vínculo: 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
Vínculo: NoteType (required): The presentation types of notes.
.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... 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 Processing errors
.... 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 Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Código do erro
Vínculo: Adjudication Error Codes (example): The adjudication error codes.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
...... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/fhir/CodeSystem/adjudication-error
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept

doco Documentação para este formato

Terminologia Ligações

CaminhoConformidadeValueSet / CódigoURI
ClaimResponse.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From a norma FHIR
Vínculos adicionais Objetivo
AllLanguages Vínculo máximo
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From a norma FHIR
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
From a norma FHIR
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
From a norma FHIR
ClaimResponse.subType.coding.coderequiredhttps://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
ClaimResponse.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From a norma FHIR
ClaimResponse.insurer.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
From a norma FHIR
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
From a norma FHIR
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From a norma FHIR
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
From a norma FHIR
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From a norma FHIR
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From a norma FHIR
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
From a norma FHIR
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
From a norma FHIR
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
From a norma FHIR
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
From a norma FHIR
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
From a norma FHIR
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
From a norma FHIR
ClaimResponse.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From a norma FHIR
Vínculos adicionais Objetivo
AllLanguages Vínculo máximo
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
From a norma FHIR

Restrições

IdGrauCaminho(s)DetalhesRequisitos
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ClaimResponse

Resumo

Obrigatório: 2 elementos
Fixo: 5 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

Extensões

Esta estrutura refere-se a estas extensões:

Key Elements View

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... type Σ 1..1 CodeableConcept Tipo de resposta
Vínculo: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept Subtipo de resposta
Vínculo: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use Σ 1..1 code Tipo de uso da resposta
Vínculo: Use (required): Claim, preauthorization, predetermination.
Valor fixo: claim
... patient Σ 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created Σ 1..1 dateTime Data de criação da resposta
... insurer Σ 1..1 Reference(Organization) Ente responsável pela OCI
.... display Σ 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request Σ 1..1 Reference(Claim) Referência ao pedido original
... outcome Σ 1..1 code Resultado do processamento
Vínculo: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Mensagem explicativa do resultado
... item 0..* BackboneElement Itens processados no pedido
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 1..1 positiveInt Sequência do item
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category 1..1 CodeableConcept Categoria da adjudicação
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
..... amount 0..1 Money Valor da adjudicação
.... detail 0..* BackboneElement Detalhes da adjudicação
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* Ver adjudication (ClaimResponse) detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* Ver adjudication (ClaimResponse) detalhes da adjudicação do subDetail
... payment 0..1 BackboneElement Detalhes do pagamento
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type 1..1 CodeableConcept Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... amount 1..1 Money Valor do pagamento

doco Documentação para este formato

Terminologia Ligações

CaminhoConformidadeValueSet / CódigoURI
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From a norma FHIR
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
From a norma FHIR
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
From a norma FHIR
ClaimResponse.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From a norma FHIR
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
From a norma FHIR
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html

Restrições

IdGrauCaminho(s)DetalhesRequisitos
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from ClaimResponse

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... status 1..1 code Status da resposta
... type 1..1 CodeableConcept Tipo de resposta
.... coding
..... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-type
..... code 0..1 code Symbol in syntax defined by the system
Valor fixo: apac
.... coding
..... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-subtype
..... code 0..1 code Symbol in syntax defined by the system
Vínculo: https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype (required)
... use 1..1 code Tipo de uso da resposta
Valor fixo: claim
... patient 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created 1..1 dateTime Data de criação da resposta
... insurer 1..1 Reference(Organization) Ente responsável pela OCI
.... display 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request 1..1 Reference(Claim) Referência ao pedido original
... outcome 1..1 code Resultado do processamento
... disposition 0..1 string Mensagem explicativa do resultado
... item 0..* BackboneElement Itens processados no pedido
.... itemSequence 1..1 positiveInt Sequência do item
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... category 1..1 CodeableConcept Categoria da adjudicação
..... amount 0..1 Money Valor da adjudicação
.... detail 0..* BackboneElement Detalhes da adjudicação
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... subDetailSequence 1..1 positiveInt Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* detalhes da adjudicação do subDetail
... payment 0..1 BackboneElement Detalhes do pagamento
.... type 1..1 CodeableConcept Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... amount 1..1 Money Valor do pagamento
... error
.... code 1..1 CodeableConcept Código do erro
..... coding
...... system 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/fhir/CodeSystem/adjudication-error

doco Documentação para este formato

Terminologia Ligações (Diferencial)

CaminhoConformidadeConjunto de valoresURI
ClaimResponse.subType.coding.coderequiredhttps://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html

Snapshot View

NomeBandeirasCard.TipoDescrição e condicionalismos    Filter: Filtersdoco
.. ClaimResponse 1..* ClaimResponse Resposta a uma solicitação de reembolso ou cobertura de um procedimento de saúde.
... 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
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... 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
... Fatias para extension 0..* Extension Extensões utilizadas pela RespostaGuiaOCIBRIPES.
Fatia: Não ordenado, Aberto por value:url
.... extension:PlanoAcaoRegionalClaim 0..1 Reference() Extensão de PlanoAcaoRegionalClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/PlanoAcaoRegionalClaim
.... extension:RegistroRegulacaoAssistencialClaim 0..* Reference() Extensão de RegistroRegulacaoAssistencialClaim
URL: https://fhir.ecoinfo.ipes.tech/fhir/StructureDefinition/RegistroRegulacaoAssistencialClaim
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier 0..* Identifier Business Identifier for a claim response
... status ?!Σ 1..1 code Status da resposta
Vínculo: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Tipo de resposta
Vínculo: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-type
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Valor fixo: apac
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subType 0..1 CodeableConcept Subtipo de resposta
Vínculo: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... coding Σ 0..* Coding Code defined by a terminology system
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/CodeSystem/claim-subtype
..... version Σ 0..1 string Version of the system - if relevant
..... code Σ 0..1 code Symbol in syntax defined by the system
Vínculo: https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype (required)
..... display Σ 0..1 string Representation defined by the system
..... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... use Σ 1..1 code Tipo de uso da resposta
Vínculo: Use (required): Claim, preauthorization, predetermination.
Valor fixo: claim
... patient Σ 1..1 Reference(Paciente) Paciente relacionado ao pedido
... created Σ 1..1 dateTime Data de criação da resposta
... insurer Σ 1..1 Reference(Organization) Ente responsável pela OCI
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Vínculo: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
Padrão necessário: SUS
... requestor 1..1 Reference(Practitioner | PractitionerRole | Organization) Solicitante do pedido
... request Σ 1..1 Reference(Claim) Referência ao pedido original
... outcome Σ 1..1 code Resultado do processamento
Vínculo: ClaimProcessingCodes (required): The result of the claim processing.
... disposition 0..1 string Mensagem explicativa do resultado
... 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
Vínculo: Claim Payee Type Codes (example): A code for the party to be reimbursed.
... item 0..* BackboneElement Itens processados no pedido
.... 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 1..1 positiveInt Sequência do item
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* BackboneElement Detalhes da adjudicação
..... 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 Categoria da adjudicação
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Vínculo: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount 0..1 Money Valor da adjudicação
..... value 0..1 decimal Non-monetary value
.... detail 0..* BackboneElement Detalhes da adjudicação
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... detailSequence 1..1 positiveInt Sequência do detalhe
..... noteNumber 0..* positiveInt Número da nota
..... adjudication 1..* Ver adjudication (ClaimResponse) detalhes da adjudicação do detail
..... subDetail 0..* BackboneElement Subdetalhes da adjudicação
...... 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 Sequência do subdetalhe
...... noteNumber 0..* positiveInt Número da nota
...... adjudication 0..* Ver adjudication (ClaimResponse) detalhes da adjudicação do subDetail
... addItem 0..* BackboneElement Insurer added line items
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence 0..* positiveInt Item sequence number
.... detailSequence 0..* positiveInt Detail sequence number
.... subdetailSequence 0..* positiveInt Subdetail sequence number
.... provider 0..* Reference(Practitioner | PractitionerRole | Organization) Authorized providers
.... productOrService 1..1 CodeableConcept Billing, service, product, or drug code
Vínculo: USCLSCodes (example): Allowable service and product codes.
.... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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
Vínculo: 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
Vínculo: 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
Vínculo: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
.... subSite 0..* CodeableConcept Anatomical sub-location
Vínculo: SurfaceCodes (example): The code for the tooth surface and surface combinations.
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication 1..* Ver 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
Vínculo: USCLSCodes (example): Allowable service and product codes.
..... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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..* Ver 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
Vínculo: USCLSCodes (example): Allowable service and product codes.
...... modifier 0..* CodeableConcept Service/Product billing modifiers
Vínculo: 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..* Ver adjudication (ClaimResponse) Added items detail adjudication
... adjudication 0..* Ver adjudication (ClaimResponse) Header-level adjudication
... total Σ 0..* BackboneElement Adjudication totals
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category Σ 1..1 CodeableConcept Type of adjudication information
Vínculo: AdjudicationValueCodes (example): The adjudication codes.
.... amount Σ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Detalhes do pagamento
.... 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 Tipo de pagamento
Vínculo: https://hl7.org/fhir/R5/valueset-payment-type.html (required)
.... adjustment 0..1 Money Payment adjustment for non-claim issues
.... adjustmentReason 0..1 CodeableConcept Explanation for the adjustment
Vínculo: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
.... date 0..1 date Expected date of payment
.... amount 1..1 Money Valor do pagamento
.... identifier 0..1 Identifier Business identifier for the payment
... fundsReserve 0..1 CodeableConcept Funds reserved status
Vínculo: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
... formCode 0..1 CodeableConcept Printed form identifier
Vínculo: 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
Vínculo: NoteType (required): The presentation types of notes.
.... text 1..1 string Note explanatory text
.... language 0..1 CodeableConcept Language of the text
Vínculo: CommonLanguages (preferred): A human language.
Vínculos adicionaisObjetivo
AllLanguages Vínculo máximo
... 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 Processing errors
.... 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 Item sequence number
.... detailSequence 0..1 positiveInt Detail sequence number
.... subDetailSequence 0..1 positiveInt Subdetail sequence number
.... code 1..1 CodeableConcept Código do erro
Vínculo: Adjudication Error Codes (example): The adjudication error codes.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
..... coding Σ 0..* Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Fatia: Não ordenado, Aberto por value:url
...... system Σ 0..1 uri Identity of the terminology system
Valor fixo: https://fhir.ecoinfo.ipes.tech/fhir/CodeSystem/adjudication-error
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept

doco Documentação para este formato

Terminologia Ligações

CaminhoConformidadeValueSet / CódigoURI
ClaimResponse.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From a norma FHIR
Vínculos adicionais Objetivo
AllLanguages Vínculo máximo
ClaimResponse.statusrequiredFinancialResourceStatusCodes
http://hl7.org/fhir/ValueSet/fm-status|4.0.1
From a norma FHIR
ClaimResponse.typeextensibleClaimTypeCodes
http://hl7.org/fhir/ValueSet/claim-type
From a norma FHIR
ClaimResponse.subTypeexampleExampleClaimSubTypeCodes
http://hl7.org/fhir/ValueSet/claim-subtype
From a norma FHIR
ClaimResponse.subType.coding.coderequiredhttps://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
https://fhir.ecoinfo.ipes.tech/ValueSet/claim-subtype
ClaimResponse.userequiredFixed Value: claim
http://hl7.org/fhir/ValueSet/claim-use|4.0.1
From a norma FHIR
ClaimResponse.insurer.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
From a norma FHIR
ClaimResponse.outcomerequiredClaimProcessingCodes
http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1
From a norma FHIR
ClaimResponse.payeeTypeexampleClaim Payee Type Codes
http://hl7.org/fhir/ValueSet/payeetype
From a norma FHIR
ClaimResponse.item.adjudication.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.item.adjudication.reasonexampleAdjudicationReasonCodes
http://hl7.org/fhir/ValueSet/adjudication-reason
From a norma FHIR
ClaimResponse.addItem.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.addItem.programCodeexampleExampleProgramReasonCodes
http://hl7.org/fhir/ValueSet/ex-program-code
From a norma FHIR
ClaimResponse.addItem.location[x]exampleExampleServicePlaceCodes
http://hl7.org/fhir/ValueSet/service-place
From a norma FHIR
ClaimResponse.addItem.bodySiteexampleOralSiteCodes
http://hl7.org/fhir/ValueSet/tooth
From a norma FHIR
ClaimResponse.addItem.subSiteexampleSurfaceCodes
http://hl7.org/fhir/ValueSet/surface
From a norma FHIR
ClaimResponse.addItem.detail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.detail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.addItem.detail.subDetail.productOrServiceexampleUSCLSCodes
http://hl7.org/fhir/ValueSet/service-uscls
From a norma FHIR
ClaimResponse.addItem.detail.subDetail.modifierexampleModifierTypeCodes
http://hl7.org/fhir/ValueSet/claim-modifiers
From a norma FHIR
ClaimResponse.total.categoryexampleAdjudicationValueCodes
http://hl7.org/fhir/ValueSet/adjudication
From a norma FHIR
ClaimResponse.payment.typerequiredhttps://hl7.org/fhir/R5/valueset-payment-type.html
https://hl7.org/fhir/R5/valueset-payment-type.html
ClaimResponse.payment.adjustmentReasonexamplePaymentAdjustmentReasonCodes
http://hl7.org/fhir/ValueSet/payment-adjustment-reason
From a norma FHIR
ClaimResponse.fundsReserveexampleFunds Reservation Codes
http://hl7.org/fhir/ValueSet/fundsreserve
From a norma FHIR
ClaimResponse.formCodeexampleForm Codes
http://hl7.org/fhir/ValueSet/forms
From a norma FHIR
ClaimResponse.processNote.typerequiredNoteType
http://hl7.org/fhir/ValueSet/note-type|4.0.1
From a norma FHIR
ClaimResponse.processNote.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
From a norma FHIR
Vínculos adicionais Objetivo
AllLanguages Vínculo máximo
ClaimResponse.error.codeexampleAdjudication Error Codes
http://hl7.org/fhir/ValueSet/adjudication-error
From a norma FHIR

Restrições

IdGrauCaminho(s)DetalhesRequisitos
dom-2errorClaimResponseIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorClaimResponseIf 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-4errorClaimResponseIf 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-5errorClaimResponseIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceClaimResponseA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

This structure is derived from ClaimResponse

Resumo

Obrigatório: 2 elementos
Fixo: 5 elementos

Estruturas

Esta estrutura refere-se a estas outras estruturas:

Extensões

Esta estrutura refere-se a estas extensões:

 

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