This resource provides the adjudication details from the processing of a Claim resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

Mã phản hồi của Cổng tiếp nhận dữ liệu cho hồ sơ/bảng XML1. Không dùng thay cho MA_LK.

Allows claim responses to be distinguished and referenced.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

Original request resource reference.

The outcome of the claim, predetermination, or preauthorization processing.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

The result of the claim processing.

To advise the requestor of an overall processing outcome.

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

The adjudication for items provided on the claim.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely reference the claim item entries.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

An Extension

Một căn cứ pháp lý cụ thể, có điều/khoản và tài liệu chứng minh, cho một kết quả giám định — đặc biệt cho khoản tiền mang category denied.

Vì sao bắt buộc với từ chối. NĐ 188/2025/NĐ-CP Điều 51 khoản 2 quy định việc từ chối thanh toán "phải nêu rõ căn cứ, lý do từ chối, số tiền bị từ chối thanh toán trong biên bản giám định". Ba yếu tố đó là điều kiện của chính hành vi từ chối, không phải siêu dữ liệu tuỳ chọn. Một bản ghi chỉ nói "bị từ chối" mà không dẫn được căn cứ thì không đủ để cơ sở khám bệnh, chữa bệnh thực hiện quyền kiến nghị tại Điều 51 khoản 3.

Vì sao áp cả cho khoản bị từ chối tự động. Cũng tại khoản 2, nghĩa vụ nêu căn cứ bao gồm "cả các chi phí khám bệnh, chữa bệnh bảo hiểm y tế đề nghị cơ quan bảo hiểm xã hội thanh toán trên môi trường điện tử được trả tự động khi cơ sở khám bệnh, chữa bệnh gửi dữ liệu". Từ chối do hệ thống tự sinh không được miễn nghĩa vụ này.

Ranh giới. Extension mang căn cứ mà bên giám định VIỆN DẪN; nó không chứng minh việc viện dẫn là đúng. Đánh giá tính đúng đắn thuộc quy trình kiến nghị và cơ quan có thẩm quyền.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Category giám định từng dòng. Ưu tiên HL7 adjudication (submitted, eligible, copay, benefit) cho line-level adjudication; các subtotal cục bộ của VN Core không dùng ở line-level.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Needed to enable understanding of the context of the other information in the adjudication.

Lý do nghiệp vụ dẫn tới kết quả này. Bắt buộc với category denied/recovered theo invariant vn-claim-response-denied-complete. Danh mục là taxonomy baseline cục bộ, KHÔNG phải catalog mã từ chối chính thức: NĐ 188/2025/NĐ-CP Điều 51 không ban hành danh mục mã lý do, chỉ buộc nêu rõ lý do.

For example may indicate that the funds for this benefit type have been exhausted.

To support understanding of variance from adjudication expectations.

Số tiền của dòng giám định. Đồng Việt Nam KHÔNG có đơn vị nhỏ hơn đồng đang lưu hành, nên Money.value ghi thẳng số đồng: 200000 nghĩa là hai trăm nghìn đồng. KHÔNG nhân/chia 100 theo thói quen của các hệ tiền tệ có xu, và KHÔNG ghi phần thập phân.

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

Categorized monetary totals for the adjudication.

Totals for amounts submitted, co-pays, benefits payable etc.

To provide the requestor with financial totals by category for the adjudication.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Category tổng hợp tài chính/adjudication. Dùng ConceptMap vn-cm-bhyt-financial-field-to-adjudication để map các trường tổng tiền BHYT như T_TONGCHI, T_TONGCHI_BH, T_BHTT, T_BNCCT, T_BNTT, T_NGUONKHAC, T_NGOAIDS, T_THUOC, T_VTYT. Không encode công thức quyền lợi hoặc adjudication business rule tại profile.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Needed to convey the type of total provided.

Monetary total amount associated with the category.

Needed to convey the total monetary amount.

Payment details for the adjudication of the claim.

Needed to convey references to the financial instrument that has been used if payment has been made.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Whether this represents partial or complete payment of the benefits payable.

The type (partial, complete) of the payment.

To advise the requestor when the insurer believes all payments to have been completed.

Benefits payable less any payment adjustment.

Needed to provide the actual payment amount.

CHỈ dùng cho processing error theo semantics FHIR R4 — payload không xử lý được, tham chiếu không resolve, hồ sơ sai cấu trúc. KHÔNG dùng cho từ chối thanh toán có căn cứ pháp lý: từ chối là KẾT QUẢ của giám định (NĐ 188/2025/NĐ-CP Điều 51 khoản 1 — chi phí được xác định không đúng quy định trong quá trình giám định), còn error là việc KHÔNG giám định được. Từ chối nghiệp vụ nằm ở adjudication category denied; thu hồi sau thanh toán nằm ở recovered.

If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present.

Need to communicate processing issues to the requestor.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Provides references to the claim items.

The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Provides references to the claim details within the claim item.

The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure.

Provides references to the claim sub-details within the claim detail.

Binding thu hẹp từ VNBHYTReviewIssueVS xuống VNBHYTProcessingIssueVS (từ 0.10.0): tập đầy đủ chứa cả mã kết quả giám định như LEGAL_NON_COMPLIANT_COST, và cho phép chúng ở đây chính là cách IG trước đây khuyến khích dùng sai element. Mã kết quả giám định nay thuộc VNBHYTAdjudicationIssueVS, dùng tại adjudication.reason.

Required to convey processing errors.

Mã phản hồi của Cổng tiếp nhận dữ liệu cho hồ sơ/bảng XML1. Không dùng thay cho MA_LK.

Category giám định từng dòng. Ưu tiên HL7 adjudication (submitted, eligible, copay, benefit) cho line-level adjudication; các subtotal cục bộ của VN Core không dùng ở line-level.

Lý do nghiệp vụ dẫn tới kết quả này. Bắt buộc với category denied/recovered theo invariant vn-claim-response-denied-complete. Danh mục là taxonomy baseline cục bộ, KHÔNG phải catalog mã từ chối chính thức: NĐ 188/2025/NĐ-CP Điều 51 không ban hành danh mục mã lý do, chỉ buộc nêu rõ lý do.

Số tiền của dòng giám định. Đồng Việt Nam KHÔNG có đơn vị nhỏ hơn đồng đang lưu hành, nên Money.value ghi thẳng số đồng: 200000 nghĩa là hai trăm nghìn đồng. KHÔNG nhân/chia 100 theo thói quen của các hệ tiền tệ có xu, và KHÔNG ghi phần thập phân.

Category tổng hợp tài chính/adjudication. Dùng ConceptMap vn-cm-bhyt-financial-field-to-adjudication để map các trường tổng tiền BHYT như T_TONGCHI, T_TONGCHI_BH, T_BHTT, T_BNCCT, T_BNTT, T_NGUONKHAC, T_NGOAIDS, T_THUOC, T_VTYT. Không encode công thức quyền lợi hoặc adjudication business rule tại profile.

CHỈ dùng cho processing error theo semantics FHIR R4 — payload không xử lý được, tham chiếu không resolve, hồ sơ sai cấu trúc. KHÔNG dùng cho từ chối thanh toán có căn cứ pháp lý: từ chối là KẾT QUẢ của giám định (NĐ 188/2025/NĐ-CP Điều 51 khoản 1 — chi phí được xác định không đúng quy định trong quá trình giám định), còn error là việc KHÔNG giám định được. Từ chối nghiệp vụ nằm ở adjudication category denied; thu hồi sau thanh toán nằm ở recovered.

Binding thu hẹp từ VNBHYTReviewIssueVS xuống VNBHYTProcessingIssueVS (từ 0.10.0): tập đầy đủ chứa cả mã kết quả giám định như LEGAL_NON_COMPLIANT_COST, và cho phép chúng ở đây chính là cách IG trước đây khuyến khích dùng sai element. Mã kết quả giám định nay thuộc VNBHYTAdjudicationIssueVS, dùng tại adjudication.reason.

This resource provides the adjudication details from the processing of a Claim resource.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A unique identifier assigned to this claim response.

Allows claim responses to be distinguished and referenced.

Mã phản hồi của Cổng tiếp nhận dữ liệu cho hồ sơ/bảng XML1. Không dùng thay cho MA_LK.

Allows claim responses to be distinguished and referenced.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The purpose of this identifier.

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Identifies the purpose for this identifier, if known .

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Allows users to make use of identifiers when the identifier system is not known.

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Identifier.system is always case sensitive.

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Time period during which identifier is/was valid for use.

Organization that issued/manages the identifier.

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

The status of the resource instance.

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

A code specifying the state of the resource instance.

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

The type or discipline-style of the claim.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

A more granular claim typecode.

Some jurisdictions need a finer grained claim type for routing and adjudication.

A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

Claim, preauthorization, predetermination.

This element is required to understand the nature of the request for adjudication.

The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought.

The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction.

The date this resource was created.

Need to record a timestamp for use by both the recipient and the issuer.

The party responsible for authorization, adjudication and reimbursement.

To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient.

The provider which is responsible for the claim, predetermination or preauthorization.

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Original request resource reference.

The outcome of the claim, predetermination, or preauthorization processing.

The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete).

The result of the claim processing.

To advise the requestor of an overall processing outcome.

A human readable description of the status of the adjudication.

Provided for user display.

Reference from the Insurer which is used in later communications which refers to this adjudication.

This value is only present on preauthorization adjudications.

On subsequent claims, the insurer may require the provider to quote this value.

The time frame during which this authorization is effective.

To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply.

Type of Party to be reimbursed: subscriber, provider, other.

A code for the party to be reimbursed.

Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details.

The adjudication for items provided on the claim.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely reference the claim item entries.

Necessary to provide a mechanism to link the adjudication result to the submitted claim item.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item.

The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

An Extension

Một căn cứ pháp lý cụ thể, có điều/khoản và tài liệu chứng minh, cho một kết quả giám định — đặc biệt cho khoản tiền mang category denied.

Vì sao bắt buộc với từ chối. NĐ 188/2025/NĐ-CP Điều 51 khoản 2 quy định việc từ chối thanh toán "phải nêu rõ căn cứ, lý do từ chối, số tiền bị từ chối thanh toán trong biên bản giám định". Ba yếu tố đó là điều kiện của chính hành vi từ chối, không phải siêu dữ liệu tuỳ chọn. Một bản ghi chỉ nói "bị từ chối" mà không dẫn được căn cứ thì không đủ để cơ sở khám bệnh, chữa bệnh thực hiện quyền kiến nghị tại Điều 51 khoản 3.

Vì sao áp cả cho khoản bị từ chối tự động. Cũng tại khoản 2, nghĩa vụ nêu căn cứ bao gồm "cả các chi phí khám bệnh, chữa bệnh bảo hiểm y tế đề nghị cơ quan bảo hiểm xã hội thanh toán trên môi trường điện tử được trả tự động khi cơ sở khám bệnh, chữa bệnh gửi dữ liệu". Từ chối do hệ thống tự sinh không được miễn nghĩa vụ này.

Ranh giới. Extension mang căn cứ mà bên giám định VIỆN DẪN; nó không chứng minh việc viện dẫn là đúng. Đánh giá tính đúng đắn thuộc quy trình kiến nghị và cơ quan có thẩm quyền.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Category giám định từng dòng. Ưu tiên HL7 adjudication (submitted, eligible, copay, benefit) cho line-level adjudication; các subtotal cục bộ của VN Core không dùng ở line-level.

For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Needed to enable understanding of the context of the other information in the adjudication.

Lý do nghiệp vụ dẫn tới kết quả này. Bắt buộc với category denied/recovered theo invariant vn-claim-response-denied-complete. Danh mục là taxonomy baseline cục bộ, KHÔNG phải catalog mã từ chối chính thức: NĐ 188/2025/NĐ-CP Điều 51 không ban hành danh mục mã lý do, chỉ buộc nêu rõ lý do.

For example may indicate that the funds for this benefit type have been exhausted.

To support understanding of variance from adjudication expectations.

Số tiền của dòng giám định. Đồng Việt Nam KHÔNG có đơn vị nhỏ hơn đồng đang lưu hành, nên Money.value ghi thẳng số đồng: 200000 nghĩa là hai trăm nghìn đồng. KHÔNG nhân/chia 100 theo thói quen của các hệ tiền tệ có xu, và KHÔNG ghi phần thập phân.

For example: amount submitted, eligible amount, co-payment, and benefit payable.

Most adjuciation categories convey a monetary amount.

A non-monetary value associated with the category. Mutually exclusive to the amount element above.

For example: eligible percentage or co-payment percentage.

Some adjudication categories convey a percentage or a fixed value.

A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

The adjudication for details provided on the claim.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely reference the claim detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim detail.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

A sub-detail adjudication of a simple product or service.

The adjudication for sub-details provided on the claim.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

A number to uniquely reference the claim sub-detail entry.

Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail.

The numbers associated with notes below which apply to the adjudication of this item.

Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item.

The adjudication results.

The first-tier service adjudications for payor added product or service lines.

Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Claim items which this service line is intended to replace.

Provides references to the claim items.

The sequence number of the details within the claim item which this line is intended to replace.

Provides references to the claim details within the claim item.

The sequence number of the sub-details within the details within the claim item which this line is intended to replace.

Provides references to the claim sub-details within the claim detail.

The providers who are authorized for the services rendered to the patient.

Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization.

When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Allowable service and product codes.

Necessary to state what was provided or done.

Item typification or modifiers codes to convey additional context for the product or service.

For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

To support inclusion of the item for adjudication or to charge an elevated fee.

Identifies the program under which this may be recovered.

For example: Neonatal program, child dental program or drug users recovery program.

Program specific reason codes.

Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

The date or dates when the service or product was supplied, performed or completed.

Needed to determine whether the service or product was provided during the term of the insurance coverage.

Where the product or service was provided.

Place of service: pharmacy, school, prison, etc.

The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

The number of repetitions of a service or product.