FHIR IG Statistics: StructureDefinition/profile-claim-response-prior

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{
  "resourceType": "StructureDefinition",
  "id": "profile-claim-response-prior",
  "url": "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-claim-response-prior",
  "name": "PriorClaimResponse",
  "title": "Prior Claim Response Details",
  "status": "draft",
  "description": "Prior Claim Response",
  "purpose": "To convey claim response details from a prior claim",
  "fhirVersion": "4.0.1",
  "kind": "resource",
  "abstract": false,
  "type": "ClaimResponse",
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
  "derivation": "constraint",
  "differential": {
    "element": [
      {
        "id": "ClaimResponse",
        "path": "ClaimResponse",
        "comment": "CPHA Mapping:   Response Status - E.05.03 where the following codes apply\r\nA=accepted as transmitted - no adjustments\r\nB=accepted with Rx price adjustment\r\nD=pay cardholder claim accepted (indicated using payee type)"
      },
      {
        "id": "ClaimResponse.id",
        "path": "ClaimResponse.id",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.identifier",
        "path": "ClaimResponse.identifier",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "assigner.identifier.type.coding.system"
            }
          ],
          "rules": "open"
        },
        "comment": "Usage Note:    This is an internal reference number assigned to each claim by the processor.    As this is a prior claim response this is not required"
      },
      {
        "id": "ClaimResponse.status",
        "path": "ClaimResponse.status",
        "comment": "Usage Note:   Reject claim responses may be included but are still considered active.   Example: drug not covered may be included, but patient's coverage expired may not be sent\r\nCPHA Mapping:  None\r\nThis element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.",
        "fixedCode": "active",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.type",
        "path": "ClaimResponse.type",
        "comment": "Usage:  Fixed value of Pharmacy to align with the request\r\n\r\nThis may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.type.coding",
        "path": "ClaimResponse.type.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.type.coding.system",
        "path": "ClaimResponse.type.coding.system",
        "fixedUri": "http://terminology.hl7.org/CodeSystem/claim-type",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.type.coding.code",
        "path": "ClaimResponse.type.coding.code",
        "min": 1,
        "fixedCode": "pharmacy",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.subType",
        "path": "ClaimResponse.subType",
        "comment": "Conformance Rule:   This will be used to convey the \"type\" of Claim/Claim Response in accordance with the Plan Type.  Set value = \"public\" or \"private\", \"patientAssistedCard\" or \"unknown\".\r\nRationale:   This value will be conveyed in downstream claim requests (eg secondary, tertiary), as part of the Prior Claim Response to assist in proper coordination of benefits.    This will be mapped from prior claim responses\r\nCPHA Map:  None:  This is a new data element\r\nThis may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.",
        "min": 1
      },
      {
        "id": "ClaimResponse.subType.coding",
        "path": "ClaimResponse.subType.coding",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.subType.coding.system",
        "path": "ClaimResponse.subType.coding.system",
        "fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/claim-response-subType",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.subType.coding.code",
        "path": "ClaimResponse.subType.coding.code",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.subType.text",
        "path": "ClaimResponse.subType.text",
        "min": 1,
        "fixedString": "prior"
      },
      {
        "id": "ClaimResponse.use",
        "path": "ClaimResponse.use",
        "fixedCode": "claim",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.patient",
        "path": "ClaimResponse.patient",
        "comment": "Usage Note:   The same resource from the request may be included here\r\nCPHA Mapping:  None\r\n\r\nReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.",
        "type": [
          {
            "code": "Reference",
            "targetProfile": [
              "http://hl7.org/fhir/StructureDefinition/Patient",
              "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/profile-patient"
            ],
            "aggregation": [
              "bundled"
            ]
          }
        ],
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.patient.reference",
        "path": "ClaimResponse.patient.reference",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.created",
        "path": "ClaimResponse.created",
        "comment": "CPHA Mapping:   Adjudication Date E.01.03",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.insurer",
        "path": "ClaimResponse.insurer",
        "comment": "Usage Note:    This may be considered as private; howver as this is a mandatory element a display value of \"not available\" may be used\r\nReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository."
      },
      {
        "id": "ClaimResponse.insurer.identifier",
        "path": "ClaimResponse.insurer.identifier",
        "comment": "Usage Note:   Under some circumstances (eg same insurer), this may be used.   Otherwise the display (\"not available or not permitted) must be present.\r\n\r\nWhen an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference.  For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport).  One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.insurer.identifier.system",
        "path": "ClaimResponse.insurer.identifier.system",
        "min": 1,
        "fixedUri": "http://pharmacyeclaims.ca/FHIR/CPHA-identifier/IIN",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.insurer.identifier.value",
        "path": "ClaimResponse.insurer.identifier.value",
        "comment": "CPHA Mapping:  IIN ( Issuer Identification Number)    A.01.01\r\n\r\nIf the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.  The value's primary purpose is computational mapping.  As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.)  A value formatted for human display can be conveyed using the [Rendered Value extension](extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.insurer.display",
        "path": "ClaimResponse.insurer.display",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.request",
        "path": "ClaimResponse.request",
        "comment": "Usage Note:   This field is limited to a single identifier.  Adjudicators will include both identifiers from the request message (claim.identifier).   The trace number from the Claim Request.identifier (display, limited to 6N) and the FHIR claim. identifier from the request which is an unlimited identifier.   \r\nUsage Note:  The number assigned, by the provider, to the transaction to which this response applies.   \r\r\nCPHA Mapping: Trace Number B.23.03  (in display)\r\n\r\nReferences SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.request.extension:PriorClaimInterventionCodes",
        "path": "ClaimResponse.request.extension",
        "sliceName": "PriorClaimInterventionCodes",
        "definition": "Intervention codes from a prior claim",
        "comment": "Usage Rule:   For prior claims, this is the list of intervention codes contained in the prior claim.   This is necessary as the prior adjudicator may support a different set of intervention codes as they use a different protocol (eg RAMQ, NeCST, CPHA3).    The code system (assigning authority, which align to the protocol, eg RAMQ, NeCST) and the intervention/exception code.  The display name associated with the code t is also recommended.",
        "type": [
          {
            "code": "Extension",
            "profile": [
              "http://pharmacyeclaims.ca/FHIR/v1.0/StructureDefinition/ext-prior-intervention-codes"
            ]
          }
        ],
        "isModifier": false
      },
      {
        "id": "ClaimResponse.request.identifier",
        "path": "ClaimResponse.request.identifier",
        "comment": "Usage Note:  This will be the Claim.identifier (slice Claim-identifier) from the request message.   As this is a prior claim response, this will only be used under certain conditions as established by the implementer.\r\n\r\nWhen an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference.  For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport).  One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.request.identifier.system",
        "path": "ClaimResponse.request.identifier.system",
        "min": 1,
        "fixedUri": "http://pharmacyeclaims.ca/FHIR/CPHA-identifier/trace-number",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.request.identifier.value",
        "path": "ClaimResponse.request.identifier.value",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.request.display",
        "path": "ClaimResponse.request.display",
        "comment": "Usage Note:   This is limited to 6N in order to support backward compatibility to CPHA  This will be the trace number from the Claim Request.identifier.value  The number assigned, by the provider, to the transaction to which this response applies.   This is limited to 6N, in order to maintain backward compatibility with CPHA.     This is optional as the Trace number can be deprecated once all implementations natively support FHIR.\r\r\nCPHA Mapping: Trace Number B.23.03\r\n\r\nThis is generally not the same as the Resource.text of the referenced resource.  The purpose is to identify what's being referenced, not to fully describe it.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.outcome",
        "path": "ClaimResponse.outcome",
        "comment": "Usage Note:   This can be set to \"complete\" or \"error\" \r\nCPHA Map:  E.05.03 Response Status   The decision as set in the prior adjudication result.   A value of \"A\" (accepted) or \"R\" rejected will be set in CPHA, which maps to \"complete\" or \"error\".\r\n\r\nThe resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.disposition",
        "path": "ClaimResponse.disposition",
        "comment": "CPHA Map:   Response Status E.05.03\r\nThis indicates the status of the claim response or prior claim response\r\n** May wish to codify and use an extension?  This code set is under review.\r\n\r\nSet values = A or B or C, etc.. as follows:\r\n\r\nA=accepted as transmitted - no adjustments\r\nB=accepted with Rx price adjustment\r\nC=claim captured for batch processing\r\nD=pay cardholder claim accepted\r\nR=rejected claim/reversal\r\nV=reversal accepted\r\nNote that FHIR strings SHALL NOT exceed 1MB in size",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payeeType",
        "path": "ClaimResponse.payeeType",
        "comment": "*Must be reviewed\r\nUsage Rule:  Determines who the adjudicator/insurer will issue payment to.  Set value = \"subscriber\" or \"provider\".  The pay subscriber option may be used if the network is down, and when the pharmacy has collected from the patient and is submitting on their behalf.\r\nUsage Note:  This may not be present if the claim was rejected; otherwise this must be populated\r\nCPHA Mapping:   Transaction code E,03,03.  \r\nValue of \"provider\" maps to 51=response to a pay provider claim for real-time adjudication\r\nValue of \"subscriber\" maps to 54=response to a pay cardholder claim If value = subscriber, maps to CPHA  \r\n\r\nNot all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payeeType.coding",
        "path": "ClaimResponse.payeeType.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payeeType.coding.system",
        "path": "ClaimResponse.payeeType.coding.system",
        "min": 1,
        "fixedUri": "http://terminology.hl7.org/CodeSystem/payeetype",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payeeType.coding.code",
        "path": "ClaimResponse.payeeType.coding.code",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item",
        "path": "ClaimResponse.item",
        "comment": "Usage Note:  Identifies the item submitted and the associated adjudication results.   This is a sub-set of the claim response from the prior payor",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.itemSequence",
        "path": "ClaimResponse.item.itemSequence",
        "comment": "Usage Note:   This is the claim.item.sequence from the request message.   Typically this will be a value of \"1\".\r\nCPHA Mapping:  None\r\n\r\n32 bit number; for values larger than this, use decimal",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication",
        "path": "ClaimResponse.item.adjudication",
        "slicing": {
          "discriminator": [
            {
              "type": "value",
              "path": "category.coding.code"
            }
          ],
          "rules": "open"
        },
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true,
        "binding": {
          "strength": "extensible",
          "valueSet": "http://pharmacyeclaims.ca/FHIR/ValueSet/adjudication-category-codes"
        }
      },
      {
        "id": "ClaimResponse.item.adjudication.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication.category.coding.system",
        "path": "ClaimResponse.item.adjudication.category.coding.system",
        "fixedUri": "http://pharmacyeclaims.ca/FHIR/CodeSystem/adjudication-category-codes",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication.category.coding.display",
        "path": "ClaimResponse.item.adjudication.category.coding.display",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication.reason",
        "path": "ClaimResponse.item.adjudication.reason",
        "comment": "Usage Note:   Future consideration if desired by implementers.   This would allow the response codes to be directly associated with each cutback/amount paid.    Mapping Note:   Where known, this could map to the Response/error code specific to the adjudicated amount (eg drug cost, upcharge, professional fee, etc)  Mapping at the specific area, versus to the entire claim level would be new to split out error and cutbacks, as they are combined together in CPHA.\r\nCPHA Mapping:   - Optional and TBD- Response Codes E.06.03, where an adjudication system is sophisticated enough to associated the reason for cutback to each specific cost breakdown.   \r\n\r\nFor example may indicate that the funds for this benefit type have been exhausted."
      },
      {
        "id": "ClaimResponse.item.adjudication.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoPayToCollect",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "CoPayToCollect",
        "comment": "Usage:  The co pay amount which the provider collects from the beneficiary for a specific claim.  This refers to \"co pay\" as defined in the carrier's benefit brochure.\r\nCPHA Map:  Copay to Collect  E.15.03  Optional D6",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoPayToCollect.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoPayToCollect.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoPayToCollect.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "Co-Pay",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoPayToCollect.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DeductibleToCollect",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "DeductibleToCollect",
        "comment": "Usage:  The deductible amount which the provider collects from the beneficiary for a specific claim.  This refers to \"deductible\" as defined in the carrier's benefit brochure.\r\nCPHA Map:  Deductible to Collect E.16.03  Optional D6",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DeductibleToCollect.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DeductibleToCollect.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DeductibleToCollect.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "Deductible",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DeductibleToCollect.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoInsuranceToCollect",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "CoInsuranceToCollect",
        "comment": "Usage:  The co-insurance amount which the provider collects from the beneficiary for a specific claim.  This refers to \"co-insurance\" as defined in the carrier's benefit brochure.\r\nCPHA Map:  Co-Insurance to Collect E.17.03  Optional D6",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoInsuranceToCollect.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoInsuranceToCollect.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoInsuranceToCollect.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "CoInsurance",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CoInsuranceToCollect.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DrugCost",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "DrugCost",
        "comment": "CPHA Map:  E.08.03 Drug Cost/Product Value",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DrugCost.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DrugCost.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DrugCost.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "DrugCost",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:DrugCost.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:Upcharge",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "Upcharge",
        "comment": "CPHA Map:  E.09.03  Cost Upcharge",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:Upcharge.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:Upcharge.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:Upcharge.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "Upcharge",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:Upcharge.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:GenericIncentive",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "GenericIncentive",
        "comment": "CPHA Map: E.10.03 Generic Incentive",
        "max": "1"
      },
      {
        "id": "ClaimResponse.item.adjudication:GenericIncentive.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:GenericIncentive.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:GenericIncentive.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "GenericIncentive",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:GenericIncentive.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ProfessionalFee",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "ProfessionalFee",
        "comment": "CPHA:  E.12.03 Professional Fee",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ProfessionalFee.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ProfessionalFee.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ProfessionalFee.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "ProfFee",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ProfessionalFee.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CompoundingCharge",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "CompoundingCharge",
        "comment": "CPHA Map:  E.13.03 Compounding Charge",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CompoundingCharge.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CompoundingCharge.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CompoundingCharge.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "CompoundingCharge",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:CompoundingCharge.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:SSF",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "SSF",
        "comment": "CPHA Map:  E.14.03 Special Services Fee",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:SSF.category",
        "path": "ClaimResponse.item.adjudication.category",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:SSF.category.coding",
        "path": "ClaimResponse.item.adjudication.category.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:SSF.category.coding.code",
        "path": "ClaimResponse.item.adjudication.category.coding.code",
        "min": 1,
        "fixedCode": "SSF",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:SSF.amount",
        "path": "ClaimResponse.item.adjudication.amount",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes",
        "path": "ClaimResponse.item.adjudication",
        "sliceName": "ResponseCodes",
        "comment": "Usage:   To capture the response codes / error messages returned by the 1st payer.   For example, if a drug where 1st payer in Quebec is returned as having been processed but 0$ paid, the error message is helpful to the secondary payor.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.category",
        "path": "ClaimResponse.item.adjudication.category",
        "comment": "Usage Note:  Set value = \"ResponseCode\"    In future, more granular categories may be defined.\r\n\r\nFor example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc."
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.reason",
        "path": "ClaimResponse.item.adjudication.reason",
        "comment": "CPHA Map:  Response Codes E.06.03   A/N10\r\nUsage Note:   Codes to define responses that identify errors and other reasons that may cause the claim(s) to be altered or rejected.   In CPHA, the Field length of 10 will accommodate 5 response codes per claim.   In FHIR, this is a list with a practical maximum of 20 codes.   Note:  error codes may be moved out of the repsonse codes \r\n\r\nFor example may indicate that the funds for this benefit type have been exhausted.",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.reason.coding",
        "path": "ClaimResponse.item.adjudication.reason.coding",
        "max": "1"
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.reason.coding.system",
        "path": "ClaimResponse.item.adjudication.reason.coding.system",
        "comment": "Usage Note:  Adjudicators may use their own code systems, or implementers may use a default system value - http://pharmacyeclaims.ca/FHIR/CodeSystem/FHIR-response-codes or http://pharmacyeclaims.ca/FHIR/CodeSystem/CPHA-response-codes when the codes are from a CPHA response.\r\n\r\nUsage Note:   This is not mandatory as it will only be required when code sets are not synchronized which may happen over time as codes become deprecated or new codes are added.\r\n\r\nThe URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...).  OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.reason.coding.code",
        "path": "ClaimResponse.item.adjudication.reason.coding.code",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.item.adjudication:ResponseCodes.reason.text",
        "path": "ClaimResponse.item.adjudication.reason.text",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment",
        "path": "ClaimResponse.payment",
        "comment": "Usage:  The conveyes (in amount) the total amount payable, by the insurer, to the provider for product, services and taxes for a specific claim or to the patient.   Refer to the payee type to understand who the payment was directed to. This includes all amounts in the \"ClaimResponse.item.adjudication\" section (eg DrugCostProductValue, CostUpcharge, GenericIncentive.. etc) less any amount paid by the beneficiary \r\nUsage:   There is no size restriction on this dollar amount field",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.type",
        "path": "ClaimResponse.payment.type",
        "comment": "CPHA Mapping:   None.  \r\nUsage:  This amount must be derived.   If the paid amount is less than submitted, value = \"partial\", else \"complete\"\r\n\r\nNot all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.type.coding",
        "path": "ClaimResponse.payment.type.coding",
        "min": 1,
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.type.coding.system",
        "path": "ClaimResponse.payment.type.coding.system",
        "comment": "Usage:  This is a fixed value\r\nThe URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...).  OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.",
        "min": 1,
        "fixedUri": "http://hl7.org/fhir/ValueSet/ex-paymenttype",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.type.coding.code",
        "path": "ClaimResponse.payment.type.coding.code",
        "comment": "Usage:  Set value = \"partial\" or \"complete\"\r\nNote that FHIR strings SHALL NOT exceed 1MB in size",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.amount",
        "path": "ClaimResponse.payment.amount",
        "comment": "Usage:  The total amount payable, by the insurer, to the provider or patient/insured party for product, services and taxes for a specific claim. This includes all amounts in the \"ClaimResponse.item.adjudication\" section (eg DrugCostProductValue, CostUpcharge, GenericIncentive.. etc) less any amount paid by the beneficiary.\r\nUsage:  There is no size restriction on this dollar amount field\r\nCPHA Mapping:  Plan Pays E.19.03 D6",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.payment.amount.value",
        "path": "ClaimResponse.payment.amount.value",
        "min": 1,
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote",
        "path": "ClaimResponse.processNote",
        "comment": "Usage:  Detailed response information.  \r\nConformance Rule:   A maximum of 1000 characters may be returned for each note\r\nConformance Rule:   A maximum of 10 notes can be returned; this allows for a given note to be returned in both english and french and therefore allows up to 20 instances.    \r\nConformance Rule:   Where possible adjudicators must return both english and french as this allows the vendor to display the note in the language of the user.\r\nConformance Rule:    Vendors must co-relate french and english notes by assigning the same processNote.number\r\nConformance Rule:   When the adjudicator does not know whether a note is french or english, the language.text must contain a value of \"unknown\".\r\n\r\nCPHA Map:  Message Data Lines 1,2,3  E.20.03, E.21.03, E.22.03  A/N40",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.number",
        "path": "ClaimResponse.processNote.number",
        "comment": "Usage Note:   When an adjudicator returns the same note in both english and french, this number must be used to co-relate the notes.     Vendors must co-relate french and english notes by assigning the same processNote.number\r\n\r\n32 bit number; for values larger than this, use decimal",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.type",
        "path": "ClaimResponse.processNote.type",
        "comment": "Usage Notes:   Systems that natively support FHIR must support this\r\nCPHA Mapping:  None\r\n\r\nNote that FHIR strings SHALL NOT exceed 1MB in size",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.text",
        "path": "ClaimResponse.processNote.text",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.language",
        "path": "ClaimResponse.processNote.language",
        "comment": "Conformance Rule:   This must be populated with a code of \"en\" for English or \"fr\" for French, OR,  if unknown, do not use a code and instead populate the text value with \"unknown\".    Where possible, both english and french messages should be included\r\n???? TWG discussion to ensure this meets the need.   \r\nCPHA Mapping:  None.   New requirement\r\nOnly required if the language is different from the resource language.",
        "min": 1,
        "mustSupport": true,
        "binding": {
          "strength": "required",
          "valueSet": "http://hl7.org/fhir/ValueSet/all-languages"
        }
      },
      {
        "id": "ClaimResponse.processNote.language.coding",
        "path": "ClaimResponse.processNote.language.coding",
        "comment": "Usage:   Either system+ code must be present (for en and fr), or text must have a value of \"unknown\".\r\nCodes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.  Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.",
        "max": "1",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.language.coding.system",
        "path": "ClaimResponse.processNote.language.coding.system",
        "fixedUri": "urn:ietf:bcp:47",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.language.coding.code",
        "path": "ClaimResponse.processNote.language.coding.code",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.processNote.language.text",
        "path": "ClaimResponse.processNote.language.text",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.error",
        "path": "ClaimResponse.error",
        "comment": "CPHA Map:  Response Codes E.06.03 \r\nUsage:  Codes to define responses that identify errors and other reasons that may cause the claim(s) to be altered or rejected. Field length of 10 will accommodate 5 response codes per claim.    The first two numeric digits of the field/version numbers in sections A, B, C and D reflect error codes which indicate missing or invalid information received \r\nin the respective fields. Alphanumeric and alpha combinations provide other response messages.\r\n\r\nIf the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.error.code",
        "path": "ClaimResponse.error.code",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.error.code.coding",
        "path": "ClaimResponse.error.code.coding",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.error.code.coding.system",
        "path": "ClaimResponse.error.code.coding.system",
        "mustSupport": true
      },
      {
        "id": "ClaimResponse.error.code.coding.code",
        "path": "ClaimResponse.error.code.coding.code",
        "min": 1,
        "mustSupport": true
      }
    ]
  }
}