Hướng dẫn triển khai FHIR cốt lõi Việt Nam — VN Core FHIR Implementation Guide - Draft for Community Review (v0.10.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Hồ sơ tài nguyên: Kết quả giải quyết BHYT VN Core — VN Core ClaimResponse Profile

Profile ClaimResponse cho Việt Nam. Kết quả xử lý yêu cầu thanh toán BHYT.

Đây là nơi nhận kết quả giám định của cơ quan bảo hiểm xã hội (ADR-0021 quyết định D6). Cơ quan bảo hiểm xã hội trả kết quả giám định chứ không phát hành ExplanationOfBenefit; ClaimResponse.item.adjudication trong FHIR R4 vốn đã là 1..* nên chịu được toàn bộ kết quả theo từng dòng. ExplanationOfBenefit lùi về vai trò tuỳ chọn, hướng người bệnh — dùng khi cần trình bày lại chi phí trên Sổ sức khoẻ điện tử.

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. Một đợt KCB được biểu diễn bằng một Claim với một MA_LK; Claim có thể mang nhiều insurance khi người bệnh được cấp thẻ mới giữa đợt hoặc có đồng thời nhiều thẻ/quyền lợi, và đúng một mục là focal = true. Một ClaimResponse phản hồi toàn bộ hồ sơ đó. Claim.related vẫn là quan hệ tuỳ chọn theo ngữ nghĩa FHIR prior/associated; VN Core không đặt nghĩa vụ hỗ trợ tối thiểu và không dùng phần tử này để hướng dẫn chia đợt hoặc sinh MA_LK mới. Luồng điều chỉnh/bổ sung chưa được VN Core 0.10.0 quy định mô hình FHIR. Mã phản hồi gateway như XML1_ID được biểu diễn bằng identifier slice riêng; không thay thế MA_LK của Claim/Bundle. Căn cứ:

• QĐ 130/QĐ-BYT → QĐ 4750/QĐ-BYT → QĐ 3176/QĐ-BYT (chuẩn dữ liệu BHXH hiện hành)
• QĐ 697/QĐ-BYT (19/3/2026) — Mẫu bảng kê chi phí KCB
• TT 12/2026/TT-BTC — Điều 10–12 và Mẫu 09/BH về giám định, thông báo kết quả/từ chối và quyết toán; lựa chọn ClaimResponse là mapping FHIR cục bộ
• Luật 51/2024/QH15 (27/11/2024) — sửa đổi Luật BHYT, hiệu lực 01/7/2025
• NĐ 188/2025/NĐ-CP — ban hành 01/7/2025, hiệu lực 15/8/2025 — Hướng dẫn Luật BHYT
• NĐ 90/2026/NĐ-CP (ban hành 30/03/2026, hiệu lực 15/05/2026 — đang áp dụng) — xử phạt VPHC y tế, tham chiếu khi hồ sơ giám định/thanh toán sai lệch Nguồn thiết kế: OHP Data Processor (ClaimResponse adjudication mapping).

Usages:

• Refer to this Profile: Kiến nghị xem xét lại chi phí BHYT — VN Core BHYT Cost Appeal Task and Đối soát và phân bổ khoản thanh toán BHYT — VN Core BHYT Payment Reconciliation
• Examples for this Profile: ClaimResponse/ExampleClaimResponseBHYT, ClaimResponse/ExampleClaimResponseDeniedWithoutEvidence, ClaimResponse/ExampleClaimResponseDetailSilentReduction, ClaimResponse/ExampleClaimResponseDuplicateAdjudicationCategory... Show 10 more, ClaimResponse/ExampleClaimResponseErrorWrongOutcome, ClaimResponse/ExampleClaimResponseForeignCurrencyPayment, ClaimResponse/ExampleClaimResponseHeaderSilentReduction, ClaimResponse/ExampleClaimResponseItemizedMultiStage, ClaimResponse/ExampleClaimResponseNotItemized, ClaimResponse/ExampleClaimResponseOrphanActive, ClaimResponse/ExampleClaimResponsePartialDeny, ClaimResponse/ExampleClaimResponseSelfPay, ClaimResponse/ExampleClaimResponseSilentReduction and ClaimResponse/ExampleClaimResponseTotalOnlyReduction
• CapabilityStatements using this Profile: VN Core BHYT Gateway Client CapabilityStatement, VN Core BHYT Gateway Server CapabilityStatement and VN Core Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

Các dạng xem hình thức của nội dung hồ sơ

Mô tả profile, differential, snapshot và các biểu diễn liên quan.

• Bảng phần tử chính
• Bảng Differential
• Bảng Snapshot
• Nghĩa vụ hỗ trợ
• Thống kê/Tham chiếu
• Tất cả

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	SΣ	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương Example General: 123456
status	?!SOΣ	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. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SOΣ	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	SOΣ	1..1	code	Mục đích: claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SOΣ	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SOΣ	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
request	SOΣ	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SOΣ	1..1	code	Kết quả: queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
item	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
total	SOΣ	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.identifier:gatewayResponseId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​type	Base	extensible	IdentifierType	📍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.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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
ClaimResponse.total.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.payment.​type	Base	example	Example Payment Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

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()
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type		0..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
system		1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	S	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương
status	SO	1..1	code	Trạng thái kết quả: active | cancelled | draft | entered-in-error Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SO	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	SO	1..1	code	Mục đích: claim | preauthorization | predetermination Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SO	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SO	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SO	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
request	SO	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SO	1..1	code	Kết quả: queued | complete | error | partial Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
item	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
total	SO	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
category	S	1..1	CodeableConcept	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
itemSequence	S	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.item.adjudication.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
ClaimResponse.total.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.error.​code	Base	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	SΣ	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SOΣ	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. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SOΣ	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SOΣ	1..1	code	Mục đích: claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SOΣ	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SOΣ	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SOΣ	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SOΣ	1..1	code	Kết quả: queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
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	SOΣ	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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 Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​type	Base	extensible	IdentifierType	📍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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
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	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

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()
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Summary

Mandatory: 0 element(2 nested mandatory elements)
Must-Support: 26 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-claim)

Extensions

This structure refers to these extensions:

• http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of ClaimResponse.identifier

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Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	SΣ	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương Example General: 123456
status	?!SOΣ	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. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SOΣ	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	SOΣ	1..1	code	Mục đích: claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SOΣ	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SOΣ	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
request	SOΣ	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SOΣ	1..1	code	Kết quả: queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
item	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
total	SOΣ	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	SΣ	1..1	CodeableConcept	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
itemSequence	S	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.identifier:gatewayResponseId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​type	Base	extensible	IdentifierType	📍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.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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
ClaimResponse.total.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.payment.​type	Base	example	Example Payment Type Codes	📍4.0.1	FHIR Std.
ClaimResponse.error.​code	Base	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

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()
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

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Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type		0..1	CodeableConcept	Description of identifier Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
system		1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	S	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương
status	SO	1..1	code	Trạng thái kết quả: active | cancelled | draft | entered-in-error Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SO	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
use	SO	1..1	code	Mục đích: claim | preauthorization | predetermination Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SO	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SO	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SO	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
request	SO	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SO	1..1	code	Kết quả: queued | complete | error | partial Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
item	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
total	SO	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
category	S	1..1	CodeableConcept	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
itemSequence	S	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.item.adjudication.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
ClaimResponse.total.​category	Base	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.error.​code	Base	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

Dạng xem SnapshotView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
ClaimResponse	C	0..*	ClaimResponse	Response to a claim predetermination or preauthorization Constraints: vn-claim-response-error-outcome-coherent, vn-claim-response-denied-complete, vn-claim-response-itemized, vn-claim-response-total-matches-items, vn-claim-response-reduction-evidenced, vn-claim-response-reduction-evidenced-nested, vn-claim-response-reduction-evidenced-header, vn-claim-response-adjudication-unique-category, vn-claim-response-correlation-anchor, vn-claim-response-money-vnd
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 Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
Slices for identifier	SO	0..*	Identifier	Định danh kết quả xử lý, bao gồm mã phản hồi gateway nếu có Slice: Unordered, Open by value:system Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
identifier:gatewayResponseId	SO	0..1	Identifier	Mã phản hồi Cổng tiếp nhận BHYT (XML1_ID) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hl7.org.vn/core/CodeSystem/vn-identifier-type-cs
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: BHYT_XML1_ID
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
system	Σ	1..1	uri	The namespace for the identifier value Fixed Value: http://fhir.hl7.org.vn/core/sid/bhyt-gateway-response-id
value	SΣ	1..1	string	Giá trị XML1_ID hoặc mã phản hồi tương đương Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
status	?!SOΣ	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. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
type	SOΣ	1..1	CodeableConcept	Loại: institutional (nội trú) | professional (ngoại trú) Binding: ClaimTypeCodes (extensible): The type or discipline-style of the claim. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
subType		0..1	CodeableConcept	More granular claim type Binding: ExampleClaimSubTypeCodes (example): A more granular claim typecode.
use	SOΣ	1..1	code	Mục đích: claim | preauthorization | predetermination Binding: Use (required): Claim, preauthorization, predetermination. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
patient	SOΣ	1..1	Reference(Bệnh nhân VN Core — VN Core Patient Profile)	Bệnh nhân Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
created	SOΣ	1..1	dateTime	Ngày tạo kết quả Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
insurer	SOΣ	1..1	Reference(Organization)	Cơ quan BHXH giải quyết Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
requestor		0..1	Reference(Practitioner | PractitionerRole | Organization)	Party responsible for the claim
request	SOΣ	0..1	Reference(Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile)	Yêu cầu thanh toán gốc (VNCoreClaim) Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
outcome	SOΣ	1..1	code	Kết quả: queued | complete | error | partial Binding: ClaimProcessingCodes (required): The result of the claim processing. Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	SO	0..*	BackboneElement	Kết quả từng dòng chi phí Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:legalEvidence	S	0..*	(Complex)	Căn cứ pháp lý của kết quả giám định (bắt buộc khi từ chối/thu hồi) URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
category	S	1..1	CodeableConcept	Loại: submitted | eligible | copay | benefit | denied | recovered Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
reason	S	0..1	CodeableConcept	Lý do của kết quả giám định — bắt buộc khi category là denied hoặc recovered Binding: Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet (extensible)
amount	S	0..1	Money	Số tiền (VND, đơn vị đồng — xem quy ước đơn vị tiền bên dưới)
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	SOΣ	0..*	BackboneElement	Tổng adjudication Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	Loại tổng: submitted | eligible | copay | benefit hoặc category BHYT cục bộ Binding: Loại adjudication BHYT — BHYT Adjudication Category ValueSet (extensible)
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 Bindings Purpose AllLanguages Max Binding
communicationRequest		0..*	Reference(CommunicationRequest)	Request for additional information
insurance		0..*	BackboneElement	Patient insurance information
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
sequence		1..1	positiveInt	Insurance instance identifier
focal		1..1	boolean	Coverage to be used for adjudication
coverage		1..1	Reference(Coverage)	Insurance information
businessArrangement		0..1	string	Additional provider contract number
claimResponse		0..1	Reference(ClaimResponse)	Adjudication results
error	SO	0..*	BackboneElement	Lỗi xử lý khiến hồ sơ không adjudicate được Obligations Actor SHALL:populate-if-known Bên giám định BHYT (Adjudicator) SHALL:no-error & SHALL:handle Bên gửi hồ sơ BHYT (Submitter)
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	0..1	positiveInt	Dòng chi phí liên quan nếu có
detailSequence	S	0..1	positiveInt	Detail sequence number
subDetailSequence	S	0..1	positiveInt	Subdetail sequence number
code	S	1..1	CodeableConcept	Mã lỗi xử lý Binding: Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet (extensible)
Documentation for this format

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
ClaimResponse.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​use	Base	required	IdentifierUse	📍4.0.1	FHIR Std.
ClaimResponse.identifier:gatewayResponseId.​type	Base	extensible	IdentifierType	📍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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
ClaimResponse.item.adjudication.​reason	Base	extensible	Issue tầng NGHIỆP VỤ — VN BHYT Adjudication Issue ValueSet	📦0.10.0	This IG
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	extensible	Loại adjudication BHYT — BHYT Adjudication Category ValueSet	📦0.10.0	This IG
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	extensible	Issue tầng XỬ LÝ — VN BHYT Processing Issue ValueSet	📦0.10.0	This IG

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()
vn-claim-response-adjudication-unique-category	error	ClaimResponse	Trong một cụm adjudication (header, item, chi tiết, chi tiết phụ, dòng bổ sung và các tầng con của nó), mỗi category HL7 chuẩn chỉ xuất hiện một lần — hợp đồng mapping OHP mà phép so sánh giảm-tiền dựa vào. Within each adjudication set every standard HL7 category SHALL appear at most once.	adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct() and item.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and item.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct()) and addItem.detail.subDetail.all(adjudication.category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication').code.isDistinct())
vn-claim-response-correlation-anchor	error	ClaimResponse	Kết quả giám định đang hiệu lực phải đối soát được BẰNG GIÁ TRỊ THẬT: request phải là reference giải quyết được (không display-only) hoặc identifier phải có value — Identifier rỗng/Reference chỉ có display không đối soát được với hồ sơ nào (siết round 3, 13/08/2026). An active ClaimResponse SHALL carry a resolvable request reference or an identifier WITH a value.	status != 'active' or request.reference.exists() or identifier.value.exists()
vn-claim-response-denied-complete	error	ClaimResponse	Khoản tiền bị từ chối hoặc bị thu hồi phải có số tiền không âm, lý do và ít nhất một căn cứ pháp lý. A denied or recovered amount SHALL carry a non-negative amount, a reason and at least one legal basis.	(adjudication | item.adjudication | item.detail.adjudication | item.detail.subDetail.adjudication | addItem.adjudication | addItem.detail.adjudication | addItem.detail.subDetail.adjudication).where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).all(amount.value.exists() and amount.value >= 0 and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists())
vn-claim-response-error-outcome-coherent	error	ClaimResponse	Có lỗi xử lý thì outcome phải là `error`. When a processing error is present, outcome SHALL be `error`.	error.empty() or outcome = 'error'
vn-claim-response-itemized	error	ClaimResponse	Phản hồi giám định phải liệt kê từng dòng chi phí, trừ khi kết quả là lỗi kỹ thuật. An adjudication response SHALL be itemized unless its outcome is an error.	outcome = 'error' or item.exists()
vn-claim-response-money-vnd	error	ClaimResponse	Mọi khoản tiền của kết quả giám định phải dùng VND. Every monetary amount in the adjudication result SHALL use VND.	descendants().ofType(Money).all(currency = 'VND')
vn-claim-response-reduction-evidenced	error	ClaimResponse	Dòng chi phí có số đủ điều kiện thấp hơn số đề nghị phải mang bằng chứng tường minh: hoặc kết quả từ chối/thu hồi (category denied/recovered kèm lý do và căn cứ), hoặc dòng eligible mang lý do + căn cứ pháp lý (khoản ngoài phạm vi hưởng) — không được giảm tiền im lặng. An item whose eligible amount is lower than submitted SHALL carry either an explicit denied/recovered adjudication or a reason plus legal basis on the eligible adjudication.	item.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-reduction-evidenced-header	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho cả adjudication cấp tổng thể của ClaimResponse. The reduction-evidence rule SHALL also hold on the header-level ClaimResponse.adjudication.	adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()
vn-claim-response-reduction-evidenced-nested	error	ClaimResponse	Quy tắc giảm-tiền-phải-có-bằng-chứng áp cho MỌI đường adjudication còn lại: dòng chi tiết, chi tiết phụ, dòng bổ sung và chi tiết/chi tiết phụ của dòng bổ sung — hậu kiểm 13/08/2026 chỉ ra addItem.detail/subDetail chưa được phủ. The reduction-evidence rule SHALL hold on item.detail, item.detail.subDetail, addItem, addItem.detail and addItem.detail.subDetail adjudications.	item.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and item.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists()) and addItem.detail.subDetail.all(adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.empty() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.first() >= adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.first() or adjudication.where(category.coding.where(system = 'http://fhir.hl7.org.vn/core/CodeSystem/vn-bhyt-adjudication-category-cs' and (code = 'denied' or code = 'recovered')).exists()).exists() or adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists() and reason.exists() and extension.where(url = 'http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence').exists()).exists())
vn-claim-response-total-matches-items	error	ClaimResponse	Mỗi tổng theo mã adjudication chuẩn phải bằng tổng các dòng cùng mã. Each total for a standard adjudication category SHALL equal the sum of the matching item adjudications.	item.empty() or ((total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'submitted').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'eligible').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'benefit').exists()).amount.value.aggregate($this + $total, 0)) and (total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() and item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.exists() implies total.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value = item.adjudication.where(category.coding.where(system = 'http://terminology.hl7.org/CodeSystem/adjudication' and code = 'copay').exists()).amount.value.aggregate($this + $total, 0)))

Name	Bên giám định BHYT (Adjudicator)	Bên gửi hồ sơ BHYT (Submitter)
ClaimResponse
Slices for identifier	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
identifier:gatewayResponseId	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
status	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
type	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
use	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
patient	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
created	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
insurer	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
request	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
outcome	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
item	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
total	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
error	SHALL:populate-if-known	SHALL:no-error & SHALL:handle
Documentation for this format

Summary

Mandatory: 0 element(2 nested mandatory elements)
Must-Support: 26 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

• Bệnh nhân VN Core — VN Core Patient Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-patient)
• Yêu cầu thanh toán KCB VN Core — VN Core Claim Profile (http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-claim)

Extensions

This structure refers to these extensions:

• http://fhir.hl7.org.vn/core/StructureDefinition/vn-ext-adjudication-legal-evidence

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the values of ClaimResponse.identifier