臺灣健保癌症用藥事前審查實作指引
1.0.8 - STU1.0.8

臺灣健保癌症用藥事前審查實作指引 - Downloaded Version 1.0.8 See the Directory of published versions

## Resource Profile: 自主審查報備-ClaimResponse Self Assessment TWPAS

Official URL: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas | Version: 1.0.8
Active as of 2025-09-26 | Computable Name: ClaimResponseSelfAssessmentTWPAS

此自主審查報備-ClaimResponse TWPAS Profile說明本IG如何進一步定義FHIR的ClaimResponse Resource以呈現自主審查報備之內容。

現行開放自主事前審查項目僅有心臟及肝臟移植，若醫院要自主事前審查需向健保署申請，通過後，健保署會於署內系統維護，具有此資格之院所才可填報自主審查報備。

Usages:

- Use this Profile: 事前審查-Bundle TWPAS
- Examples for this Profile: ClaimResponse/self-assessment-example
- CapabilityStatements using this Profile: 臺灣癌藥事前審查-用戶端(TWPAS Client) and 臺灣癌藥事前審查-伺服端(TWPAS Server)

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
meta | Σ | 1..1 | Meta | Metadata about the resource
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 0..* | BackboneElement | Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ClaimResponse.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | Pattern Value: institutional `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` From the FHIR Standard
ClaimResponse.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG

#### Constraints

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

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
meta |  | 1..1 | Meta | Metadata about the resource
profile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
status |  | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active
type |  | 1..1 | CodeableConcept | More granular claim type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient |  | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer |  | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
item |  |  |  |
adjudication |  |  |  |
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason |  | 1..1 | CodeableConcept | 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見 Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG
ClaimResponse.item.detail.adjudication.reason | required | NHIApproveItemComment(a valid code from NHI-健保事前審查-核定註記) `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-item-comment` From this IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 0..* | BackboneElement | Adjudication for claim 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 |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by 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 Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
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
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
detail |  | 0..* | BackboneElement | Adjudication for claim 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
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by 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 Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
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
reason |  | 1..1 | CodeableConcept | 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見 Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | 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 Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | 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 | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ClaimResponse.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
ClaimResponse.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
ClaimResponse.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | Pattern Value: institutional `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` From the FHIR Standard
ClaimResponse.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` From the FHIR Standard
ClaimResponse.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` From the FHIR Standard
ClaimResponse.payeeType | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG
ClaimResponse.item.detail.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.detail.adjudication.reason | required | NHIApproveItemComment(a valid code from NHI-健保事前審查-核定註記) `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-item-comment` From this IG
ClaimResponse.addItem.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` From the FHIR Standard
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes `http://hl7.org/fhir/ValueSet/service-place|4.0.1` From the FHIR Standard
ClaimResponse.addItem.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth|4.0.1` From the FHIR Standard
ClaimResponse.addItem.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.total.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1` From the FHIR Standard
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes `http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1` From the FHIR Standard
ClaimResponse.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` From the FHIR Standard
ClaimResponse.formCode | example | Form Codes `http://hl7.org/fhir/ValueSet/forms|4.0.1` From the FHIR Standard
ClaimResponse.processNote.type | required | NoteType `http://hl7.org/fhir/ValueSet/note-type|4.0.1` From the FHIR Standard
ClaimResponse.processNote.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.error.code | example | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error|4.0.1` From the FHIR Standard

#### Constraints

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

This structure is derived from ClaimResponse

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Patient-twpas)
- TW Core Organization Government (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-govt-twcore)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
meta | Σ | 1..1 | Meta | Metadata about the resource
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
item |  | 0..* | BackboneElement | Adjudication for claim line items
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 1..1 | positiveInt | Claim item instance identifier
adjudication |  | 1..* | BackboneElement | Adjudication details
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ClaimResponse.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | Pattern Value: institutional `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` From the FHIR Standard
ClaimResponse.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG

#### Constraints

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

Differential View

This structure is derived from ClaimResponse

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  |  | ClaimResponse |
meta |  | 1..1 | Meta | Metadata about the resource
profile |  | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
status |  | 1..1 | code | active | cancelled | draft | entered-in-error Required Pattern: active
type |  | 1..1 | CodeableConcept | More granular claim type Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
use |  | 1..1 | code | claim | preauthorization | predetermination Required Pattern: preauthorization
patient |  | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer |  | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
item |  |  |  |
adjudication |  |  |  |
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
detail |  |  |  |
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】
coding |  |  |  |
system |  | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
code |  | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
reason |  | 1..1 | CodeableConcept | 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見 Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG
ClaimResponse.item.detail.adjudication.reason | required | NHIApproveItemComment(a valid code from NHI-健保事前審查-核定註記) `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-item-comment` From this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
ClaimResponse |  | 0..* | ClaimResponse | Response to a claim predetermination or preauthorization
id | Σ | 0..1 | id | Logical id of this artifact
meta | Σ | 1..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | Σ | 1..1 | canonical(StructureDefinition) | Profiles this resource claims to conform to Required Pattern: https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier |  | 0..* | Identifier | Business Identifier for a claim response
status | ?!Σ | 1..1 | code | active | cancelled | draft | entered-in-error Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance. Required Pattern: active
type | Σ | 1..1 | CodeableConcept | More granular claim type Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subType |  | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use | Σ | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Required Pattern: preauthorization
patient | Σ | 1..1 | Reference(病人資訊-Patient TWPAS) | The recipient of the products and services
created | S Σ | 1..1 | dateTime | 核定日期。若申請案件類別為3時須填寫。YYYY-MM-DD，西元年月日。
insurer | Σ | 1..1 | Reference(TW Core Organization Government) | Party responsible for reimbursement
requestor |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Party responsible for the claim
request | Σ | 0..1 | Reference(Claim) | Id of resource triggering adjudication
outcome | Σ | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing.
disposition |  | 0..1 | string | Disposition Message
preAuthRef |  | 0..1 | string | Preauthorization reference
preAuthPeriod |  | 0..1 | Period | Preauthorization reference effective period
payeeType |  | 0..1 | CodeableConcept | Party to be paid any benefits payable Binding: Claim Payee Type Codes (example): A code for the party to be reimbursed.
item |  | 0..* | BackboneElement | Adjudication for claim 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 |  | 1..1 | positiveInt | Claim item instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by 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 Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
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
reason | S | 1..1 | CodeableConcept | 受理審查案件核定註記。若申請案件類別為3時須填寫。1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 Binding: NHI-健保事前審查-受理審查案件核定註記值集 (required)
amount |  | 0..1 | Money | Monetary amount
value | S | 1..1 | decimal | 核定數量，若申請案件類別為3時須填寫。
detail |  | 0..* | BackboneElement | Adjudication for claim 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
detailSequence |  | 1..1 | positiveInt | 請填寫對應的Claim.item.sequence
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | BackboneElement | Detail level adjudication details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
category |  | 1..1 | CodeableConcept | 【因FHIR設計而需必填】 Binding: AdjudicationValueCodes (example): The adjudication codes.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by 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 Slice: Unordered, Open by value:url
system | Σ | 0..1 | uri | Identity of the terminology system Example General: http://terminology.hl7.org/CodeSystem/adjudication
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ | 0..1 | code | Symbol in syntax defined by the system Example General: submitted
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
reason |  | 1..1 | CodeableConcept | 個別醫令核定註記。0:審核中 | 1:同意 | 2:不予同意 | 3:部份同意 | 4:補件 | 5:退件 | 6:不予同意:對應手術亦不支付 | 7:改核:如審查核定意見 Binding: NHI-健保事前審查-個別醫令核定註記值集 (required)
amount |  | 0..1 | Money | Monetary amount
value |  | 0..1 | decimal | Non-monetary value
subDetail |  | 0..* | BackboneElement | Adjudication for claim sub-details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
subDetailSequence |  | 1..1 | positiveInt | Claim sub-detail instance identifier
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 0..* | See adjudication (ClaimResponse) | Subdetail level adjudication details
addItem |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
itemSequence |  | 0..* | positiveInt | Item sequence number
detailSequence |  | 0..* | positiveInt | Detail sequence number
subdetailSequence |  | 0..* | positiveInt | Subdetail sequence number
provider |  | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
programCode |  | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example): Program specific reason codes.
serviced[x] |  | 0..1 |  | Date or dates of service or product delivery
servicedDate |  |  | date |
servicedPeriod |  |  | Period |
location[x] |  | 0..1 |  | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example): Place of service: pharmacy, school, prison, etc.
locationCodeableConcept |  |  | CodeableConcept |
locationAddress |  |  | Address |
locationReference |  |  | Reference(Location) |
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
bodySite |  | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example): The code for the teeth, quadrant, sextant and arch.
subSite |  | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example): The code for the tooth surface and surface combinations.
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items adjudication
detail |  | 0..* | BackboneElement | Insurer added line details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
subDetail |  | 0..* | BackboneElement | Insurer added line items
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
productOrService |  | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example): Allowable service and product codes.
modifier |  | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example): Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.
quantity |  | 0..1 | SimpleQuantity(4.0.1) | Count of products or services
unitPrice |  | 0..1 | Money | Fee, charge or cost per item
factor |  | 0..1 | decimal | Price scaling factor
net |  | 0..1 | Money | Total item cost
noteNumber |  | 0..* | positiveInt | Applicable note numbers
adjudication |  | 1..* | See adjudication (ClaimResponse) | Added items detail adjudication
adjudication |  | 0..* | See adjudication (ClaimResponse) | Header-level adjudication
total | 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 Binding: AdjudicationValueCodes (example): The adjudication codes.
amount | Σ | 1..1 | Money | Financial total for the category
payment |  | 0..1 | BackboneElement | Payment Details
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
type |  | 1..1 | CodeableConcept | Partial or complete payment Binding: ExamplePaymentTypeCodes (example): The type (partial, complete) of the payment.
adjustment |  | 0..1 | Money | Payment adjustment for non-claim issues
adjustmentReason |  | 0..1 | CodeableConcept | Explanation for the adjustment Binding: PaymentAdjustmentReasonCodes (example): Payment Adjustment reason codes.
date |  | 0..1 | date | Expected date of payment
amount |  | 1..1 | Money | Payable amount after adjustment
identifier |  | 0..1 | Identifier | Business identifier for the payment
fundsReserve |  | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example): For whom funds are to be reserved: (Patient, Provider, None).
formCode |  | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example): The forms codes.
form |  | 0..1 | Attachment | Printed reference or actual form
processNote |  | 0..* | BackboneElement | Note concerning adjudication
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
number |  | 0..1 | positiveInt | Note instance identifier
type |  | 0..1 | code | display | print | printoper Binding: NoteType (required): The presentation types of notes.
text |  | 1..1 | string | Note explanatory text
language |  | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
communicationRequest |  | 0..* | Reference(CommunicationRequest) | Request for additional information
insurance |  | 0..* | BackboneElement | Patient insurance information
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
sequence |  | 1..1 | positiveInt | Insurance instance identifier
focal |  | 1..1 | boolean | Coverage to be used for adjudication
coverage |  | 1..1 | Reference(Coverage) | Insurance information
businessArrangement |  | 0..1 | string | Additional provider contract number
claimResponse |  | 0..1 | Reference(ClaimResponse) | Adjudication results
error |  | 0..* | BackboneElement | 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 | Error code detailing processing issues Binding: Adjudication Error Codes (example): The adjudication error codes.
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet / Code | URI
ClaimResponse.meta.security | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels|4.0.1` From the FHIR Standard
ClaimResponse.meta.tag | example | CommonTags `http://hl7.org/fhir/ValueSet/common-tags|4.0.1` From the FHIR Standard
ClaimResponse.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.status | required | Pattern Value: active `http://hl7.org/fhir/ValueSet/fm-status|4.0.1` From the FHIR Standard
ClaimResponse.type | extensible | Pattern Value: institutional `http://hl7.org/fhir/ValueSet/claim-type|4.0.1` From the FHIR Standard
ClaimResponse.subType | example | ExampleClaimSubTypeCodes `http://hl7.org/fhir/ValueSet/claim-subtype|4.0.1` From the FHIR Standard
ClaimResponse.use | required | Pattern Value: preauthorization `http://hl7.org/fhir/ValueSet/claim-use|4.0.1` From the FHIR Standard
ClaimResponse.outcome | required | ClaimProcessingCodes `http://hl7.org/fhir/ValueSet/remittance-outcome|4.0.1` From the FHIR Standard
ClaimResponse.payeeType | example | Claim Payee Type Codes `http://hl7.org/fhir/ValueSet/payeetype|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.adjudication.reason | required | NHIApproveClaimComment `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment` From this IG
ClaimResponse.item.detail.adjudication.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.item.detail.adjudication.reason | required | NHIApproveItemComment(a valid code from NHI-健保事前審查-核定註記) `https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-item-comment` From this IG
ClaimResponse.addItem.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.addItem.programCode | example | ExampleProgramReasonCodes `http://hl7.org/fhir/ValueSet/ex-program-code|4.0.1` From the FHIR Standard
ClaimResponse.addItem.location[x] | example | ExampleServicePlaceCodes `http://hl7.org/fhir/ValueSet/service-place|4.0.1` From the FHIR Standard
ClaimResponse.addItem.bodySite | example | OralSiteCodes `http://hl7.org/fhir/ValueSet/tooth|4.0.1` From the FHIR Standard
ClaimResponse.addItem.subSite | example | SurfaceCodes `http://hl7.org/fhir/ValueSet/surface|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.productOrService | example | USCLSCodes `http://hl7.org/fhir/ValueSet/service-uscls|4.0.1` From the FHIR Standard
ClaimResponse.addItem.detail.subDetail.modifier | example | ModifierTypeCodes `http://hl7.org/fhir/ValueSet/claim-modifiers|4.0.1` From the FHIR Standard
ClaimResponse.total.category | example | AdjudicationValueCodes `http://hl7.org/fhir/ValueSet/adjudication|4.0.1` From the FHIR Standard
ClaimResponse.payment.type | example | ExamplePaymentTypeCodes `http://hl7.org/fhir/ValueSet/ex-paymenttype|4.0.1` From the FHIR Standard
ClaimResponse.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes `http://hl7.org/fhir/ValueSet/payment-adjustment-reason|4.0.1` From the FHIR Standard
ClaimResponse.fundsReserve | example | Funds Reservation Codes `http://hl7.org/fhir/ValueSet/fundsreserve|4.0.1` From the FHIR Standard
ClaimResponse.formCode | example | Form Codes `http://hl7.org/fhir/ValueSet/forms|4.0.1` From the FHIR Standard
ClaimResponse.processNote.type | required | NoteType `http://hl7.org/fhir/ValueSet/note-type|4.0.1` From the FHIR Standard
ClaimResponse.processNote.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages|4.0.1` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
ClaimResponse.error.code | example | Adjudication Error Codes `http://hl7.org/fhir/ValueSet/adjudication-error|4.0.1` From the FHIR Standard

#### Constraints

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

This structure is derived from ClaimResponse

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 3 elements

Structures

This structure refers to these other structures:

- 病人資訊-Patient TWPAS (https://nhicore.nhi.gov.tw/pas/StructureDefinition/Patient-twpas)
- TW Core Organization Government (https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-govt-twcore)

Other representations of profile: CSV, Excel, Schematron