VN Core FHIR Implementation Guide — Bộ Hướng dẫn Triển khai FHIR Cốt lõi cho Việt Nam
0.1.0 - STU1 Draft Viet Nam flag

VN Core FHIR Implementation Guide — Bộ Hướng dẫn Triển khai FHIR Cốt lõi cho Việt Nam - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: Kết quả giải quyết BHYT VN Core — VN Core ClaimResponse Profile

Official URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-claim-response Version: 0.1.0
Draft as of 2026-03-21 Computable Name: VNCoreClaimResponse

Profile ClaimResponse cho Việt Nam. Kết quả xử lý yêu cầu thanh toán BHYT. Bao gồm adjudication chi tiết: tổng đề nghị, đủ điều kiện, cùng chi trả, BHYT thanh toán. Cặp đôi với VNCoreClaim — Claim là yêu cầu, ClaimResponse là kết quả. Căn cứ:

  • QĐ 130/QĐ-BYT → QĐ 4750 → QĐ 3176 (chuẩn dữ liệu BHXH)
  • QĐ 697/QĐ-BYT (19/3/2026) — Mẫu bảng kê chi phí KCB
  • NĐ 188/2025/NĐ-CP — Hướng dẫn Luật BHYT Nguồn thiết kế: OHP Data Processor (ClaimResponse adjudication mapping).

Usages:

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.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... use SΣ 1..1 code Mục đích: claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... created SΣ 1..1 dateTime Ngày tạo kết quả
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... request SΣ 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome SΣ 1..1 code Kết quả: queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... item S 0..* BackboneElement Kết quả từng dòng chi phí
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... amount S 0..1 Money Số tiền (VND)
... total SΣ 0..* BackboneElement Tổng adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount SΣ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... 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.
.... amount 1..1 Money Số tiền BHXH thanh toán

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... status S 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
... type S 1..1 CodeableConcept Loại: institutional (nội trú) | professional (ngoại trú)
... use S 1..1 code Mục đích: claim | preauthorization | predetermination
... created S 1..1 dateTime Ngày tạo kết quả
... insurer S 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... request S 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome S 1..1 code Kết quả: queued | complete | error | partial
... item S 0..* BackboneElement Kết quả từng dòng chi phí
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... category S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
..... amount S 0..1 Money Số tiền (VND)
... total S 0..* BackboneElement Tổng adjudication
.... category S 1..1 CodeableConcept Type of adjudication information
.... amount S 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... amount 1..1 Money Số tiền BHXH thanh toán

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
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 ?!SΣ 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Loại: institutional (nội trú) | professional (ngoại trú)
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Mục đích: claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... created SΣ 1..1 dateTime Ngày tạo kết quả
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request SΣ 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome SΣ 1..1 code Kết quả: 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 S 0..* BackboneElement Kết quả từng dòng chi phí
.... 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 S 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... 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 S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount S 0..1 Money Số tiền (VND)
..... value 0..1 decimal Non-monetary value
.... 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 Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem 0..* BackboneElement 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 SΣ 0..* BackboneElement Tổng 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
.... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount SΣ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... 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 Số tiền BHXH thanh toán
.... 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 BindingsPurpose
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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... use SΣ 1..1 code Mục đích: claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... created SΣ 1..1 dateTime Ngày tạo kết quả
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... request SΣ 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome SΣ 1..1 code Kết quả: queued | complete | error | partial
Binding: ClaimProcessingCodes (required): The result of the claim processing.
... item S 0..* BackboneElement Kết quả từng dòng chi phí
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... category S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... amount S 0..1 Money Số tiền (VND)
... total SΣ 0..* BackboneElement Tổng adjudication
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount SΣ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... 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.
.... amount 1..1 Money Số tiền BHXH thanh toán

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... status S 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
... type S 1..1 CodeableConcept Loại: institutional (nội trú) | professional (ngoại trú)
... use S 1..1 code Mục đích: claim | preauthorization | predetermination
... created S 1..1 dateTime Ngày tạo kết quả
... insurer S 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... request S 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome S 1..1 code Kết quả: queued | complete | error | partial
... item S 0..* BackboneElement Kết quả từng dòng chi phí
.... itemSequence S 1..1 positiveInt Claim item instance identifier
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... category S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
..... amount S 0..1 Money Số tiền (VND)
... total S 0..* BackboneElement Tổng adjudication
.... category S 1..1 CodeableConcept Type of adjudication information
.... amount S 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... amount 1..1 Money Số tiền BHXH thanh toán

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. ClaimResponse 0..* ClaimResponse Response to a claim predetermination or preauthorization
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
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 ?!SΣ 1..1 code Trạng thái kết quả: active | cancelled | draft | entered-in-error
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type SΣ 1..1 CodeableConcept Loại: institutional (nội trú) | professional (ngoại trú)
Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim.
... subType 0..1 CodeableConcept More granular claim type
Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
... use SΣ 1..1 code Mục đích: claim | preauthorization | predetermination
Binding: Use (required): Claim, preauthorization, predetermination.
... patient SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... created SΣ 1..1 dateTime Ngày tạo kết quả
... insurer SΣ 1..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ quan BHXH giải quyết
... requestor 0..1 Reference(Practitioner | PractitionerRole | Organization) Party responsible for the claim
... request SΣ 0..1 Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile) Yêu cầu thanh toán gốc (VNCoreClaim)
... outcome SΣ 1..1 code Kết quả: 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 S 0..* BackboneElement Kết quả từng dòng chi phí
.... 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 S 1..1 positiveInt Claim item instance identifier
.... noteNumber 0..* positiveInt Applicable note numbers
.... adjudication S 1..* BackboneElement Phân bổ chi phí: đề nghị, đủ ĐK, cùng chi trả, BHYT thanh toán
..... 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 S 1..1 CodeableConcept Loại: submitted | eligible | copay | benefit
Binding: AdjudicationValueCodes (example): The adjudication codes.
..... reason 0..1 CodeableConcept Explanation of adjudication outcome
Binding: AdjudicationReasonCodes (example): The adjudication reason codes.
..... amount S 0..1 Money Số tiền (VND)
..... value 0..1 decimal Non-monetary value
.... 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 Claim detail instance identifier
..... noteNumber 0..* positiveInt Applicable note numbers
..... adjudication 1..* See adjudication (ClaimResponse) Detail level adjudication details
..... subDetail 0..* BackboneElement Adjudication for claim sub-details
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
...... subDetailSequence 1..1 positiveInt Claim sub-detail instance identifier
...... noteNumber 0..* positiveInt Applicable note numbers
...... adjudication 0..* See adjudication (ClaimResponse) Subdetail level adjudication details
... addItem 0..* BackboneElement 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 SΣ 0..* BackboneElement Tổng 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
.... category SΣ 1..1 CodeableConcept Type of adjudication information
Binding: AdjudicationValueCodes (example): The adjudication codes.
.... amount SΣ 1..1 Money Financial total for the category
... payment 0..1 BackboneElement Thông tin thanh toán
.... 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 Số tiền BHXH thanh toán
.... 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 BindingsPurpose
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.

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
ClaimResponse.language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
ClaimResponse.type Base extensible Claim Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.subType Base example Example Claim SubType Codes 📍4.0.1 FHIR Std.
ClaimResponse.use Base required Use 📍4.0.1 FHIR Std.
ClaimResponse.outcome Base required Claim Processing Codes 📍4.0.1 FHIR Std.
ClaimResponse.payeeType Base example PayeeType 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.item.adjudication.​reason Base example Adjudication Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​programCode Base example Example Program Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​location[x] Base example Example Service Place Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​bodySite Base example Oral Site Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​subSite Base example Surface Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.productOrService Base example USCLS Codes 📍4.0.1 FHIR Std.
ClaimResponse.addItem.​detail.subDetail.modifier Base example Modifier type Codes 📍4.0.1 FHIR Std.
ClaimResponse.total.​category Base example Adjudication Value Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​type Base example Example Payment Type Codes 📍4.0.1 FHIR Std.
ClaimResponse.payment.​adjustmentReason Base example Payment Adjustment Reason Codes 📍4.0.1 FHIR Std.
ClaimResponse.fundsReserve Base example FundsReserve 📍4.0.1 FHIR Std.
ClaimResponse.formCode Base example Forms 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​type Base required NoteType 📍4.0.1 FHIR Std.
ClaimResponse.processNote.​language Base preferred Common Languages 📍4.0.1 FHIR Std.
ClaimResponse.error.​code Base example AdjudicationError 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

 

Other representations of profile: CSV, Excel, Schematron