# 自主審查-ClaimResponse Self Assessment TWPAS - 臺灣健保事前審查實作指引 v1.1.0

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **自主審查-ClaimResponse Self Assessment TWPAS**

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

| | |
| :--- | :--- |
| *Official URL*:https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas | *Version*:1.1.0 |
| Active as of 2025-12-29 | *Computable Name*:ClaimResponseSelfAssessmentTWPAS |

 
此自主審查-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。 

**Usages:**

* Use this Profile: [免疫製劑事前審查-Bundle Immunologic Aagent TWPAS](StructureDefinition-Bundle-immunologic-agent-twpas.md) and [癌藥事前審查-Bundle TWPAS](StructureDefinition-Bundle-twpas.md)
* Examples for this Profile: [ClaimResponse/self-assessment-example](ClaimResponse-self-assessment-example.md)
* CapabilityStatements using this Profile: [臺灣事前審查-用戶端(TWPAS Client)](CapabilityStatement-CapabilityStatementTWPASClient.md) and [臺灣事前審查-伺服端(TWPAS Server)](CapabilityStatement-CapabilityStatementTWPASServer.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/tw.gov.mohw.nhi.pas|current/StructureDefinition/ClaimResponse-self-assessment-twpas)

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-ClaimResponse-self-assessment-twpas.csv), [Excel](StructureDefinition-ClaimResponse-self-assessment-twpas.xlsx), [Schematron](StructureDefinition-ClaimResponse-self-assessment-twpas.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "ClaimResponse-self-assessment-twpas",
  "url" : "https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas",
  "version" : "1.1.0",
  "name" : "ClaimResponseSelfAssessmentTWPAS",
  "title" : "自主審查-ClaimResponse Self Assessment TWPAS",
  "status" : "active",
  "date" : "2025-12-29T22:41:30+08:00",
  "publisher" : "衛生福利部中央健康保險署",
  "contact" : [
    {
      "name" : "衛生福利部中央健康保險署",
      "telecom" : [
        {
          "system" : "url",
          "value" : "https://www.nhi.gov.tw"
        }
      ]
    }
  ],
  "description" : "此自主審查-ClaimResponse TWPAS Profile說明本IG如何進一步定義FHIR的ClaimResponse Resource以呈現自主審查之內容。 \n  \n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。",
  "fhirVersion" : "4.0.1",
  "mapping" : [
    {
      "identity" : "workflow",
      "uri" : "http://hl7.org/fhir/workflow",
      "name" : "Workflow Pattern"
    },
    {
      "identity" : "w5",
      "uri" : "http://hl7.org/fhir/fivews",
      "name" : "FiveWs Pattern Mapping"
    },
    {
      "identity" : "rim",
      "uri" : "http://hl7.org/v3",
      "name" : "RIM Mapping"
    }
  ],
  "kind" : "resource",
  "abstract" : false,
  "type" : "ClaimResponse",
  "baseDefinition" : "http://hl7.org/fhir/StructureDefinition/ClaimResponse",
  "derivation" : "constraint",
  "differential" : {
    "element" : [
      {
        "id" : "ClaimResponse.meta",
        "path" : "ClaimResponse.meta",
        "min" : 1
      },
      {
        "id" : "ClaimResponse.meta.profile",
        "path" : "ClaimResponse.meta.profile",
        "min" : 1,
        "max" : "1",
        "patternCanonical" : "https://nhicore.nhi.gov.tw/pas/StructureDefinition/ClaimResponse-self-assessment-twpas"
      },
      {
        "id" : "ClaimResponse.extension",
        "path" : "ClaimResponse.extension",
        "slicing" : {
          "discriminator" : [
            {
              "type" : "value",
              "path" : "url"
            }
          ],
          "ordered" : false,
          "rules" : "open"
        },
        "min" : 1
      },
      {
        "id" : "ClaimResponse.extension:requestor",
        "path" : "ClaimResponse.extension",
        "sliceName" : "requestor",
        "short" : "審查委員身分證號",
        "min" : 1,
        "max" : "*",
        "type" : [
          {
            "code" : "Extension",
            "profile" : [
              "https://nhicore.nhi.gov.tw/pas/StructureDefinition/extension-claimResponse-requestor"
            ]
          }
        ],
        "mustSupport" : true
      },
      {
        "id" : "ClaimResponse.status",
        "path" : "ClaimResponse.status",
        "patternCode" : "active"
      },
      {
        "id" : "ClaimResponse.type",
        "path" : "ClaimResponse.type",
        "patternCodeableConcept" : {
          "coding" : [
            {
              "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
              "code" : "institutional"
            }
          ]
        }
      },
      {
        "id" : "ClaimResponse.use",
        "path" : "ClaimResponse.use",
        "patternCode" : "preauthorization"
      },
      {
        "id" : "ClaimResponse.patient",
        "path" : "ClaimResponse.patient",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "https://nhicore.nhi.gov.tw/pas/StructureDefinition/Patient-twpas"
            ]
          }
        ]
      },
      {
        "id" : "ClaimResponse.created",
        "path" : "ClaimResponse.created",
        "short" : "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。",
        "mustSupport" : true
      },
      {
        "id" : "ClaimResponse.insurer",
        "path" : "ClaimResponse.insurer",
        "type" : [
          {
            "code" : "Reference",
            "targetProfile" : [
              "https://twcore.mohw.gov.tw/ig/twcore/StructureDefinition/Organization-govt-twcore"
            ]
          }
        ]
      },
      {
        "id" : "ClaimResponse.item",
        "path" : "ClaimResponse.item",
        "min" : 1
      },
      {
        "id" : "ClaimResponse.item.adjudication.category",
        "path" : "ClaimResponse.item.adjudication.category",
        "short" : "【因FHIR設計而需必填】"
      },
      {
        "id" : "ClaimResponse.item.adjudication.category.coding.system",
        "path" : "ClaimResponse.item.adjudication.category.coding.system",
        "example" : [
          {
            "label" : "General",
            "valueUri" : "http://terminology.hl7.org/CodeSystem/adjudication"
          }
        ]
      },
      {
        "id" : "ClaimResponse.item.adjudication.category.coding.code",
        "path" : "ClaimResponse.item.adjudication.category.coding.code",
        "example" : [
          {
            "label" : "General",
            "valueString" : "submitted"
          }
        ]
      },
      {
        "id" : "ClaimResponse.item.adjudication.reason",
        "path" : "ClaimResponse.item.adjudication.reason",
        "short" : "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",
        "min" : 1,
        "mustSupport" : true,
        "binding" : {
          "strength" : "required",
          "valueSet" : "https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-claim-comment"
        }
      },
      {
        "id" : "ClaimResponse.item.adjudication.value",
        "path" : "ClaimResponse.item.adjudication.value",
        "short" : "審查結果數量，若申請案件類別為3時須填寫。",
        "min" : 1,
        "mustSupport" : true
      },
      {
        "id" : "ClaimResponse.item.detail.detailSequence",
        "path" : "ClaimResponse.item.detail.detailSequence",
        "short" : "請填寫對應的Claim.item.sequence"
      },
      {
        "id" : "ClaimResponse.item.detail.adjudication",
        "path" : "ClaimResponse.item.detail.adjudication",
        "type" : [
          {
            "code" : "BackboneElement"
          }
        ]
      },
      {
        "id" : "ClaimResponse.item.detail.adjudication.category",
        "path" : "ClaimResponse.item.detail.adjudication.category",
        "short" : "【因FHIR設計而需必填】"
      },
      {
        "id" : "ClaimResponse.item.detail.adjudication.category.coding.system",
        "path" : "ClaimResponse.item.detail.adjudication.category.coding.system",
        "example" : [
          {
            "label" : "General",
            "valueUri" : "http://terminology.hl7.org/CodeSystem/adjudication"
          }
        ]
      },
      {
        "id" : "ClaimResponse.item.detail.adjudication.category.coding.code",
        "path" : "ClaimResponse.item.detail.adjudication.category.coding.code",
        "example" : [
          {
            "label" : "General",
            "valueString" : "submitted"
          }
        ]
      },
      {
        "id" : "ClaimResponse.item.detail.adjudication.reason",
        "path" : "ClaimResponse.item.detail.adjudication.reason",
        "short" : "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",
        "min" : 1,
        "binding" : {
          "strength" : "required",
          "valueSet" : "https://nhicore.nhi.gov.tw/pas/ValueSet/nhi-approve-item-comment"
        }
      }
    ]
  }
}

```
