FHIR R4 Resource - ClaimResponse
OpenIMIS openIMIS tables mapped - tblClaim, tblClaimItems, tblClaimServices, tblInsuree
FHIR R4 | fieldOpenIMIS field | openIMIS | notesNotes | mapping status | ||||||
---|---|---|---|---|---|---|---|---|---|---|
identifier | tblClaim.ClaimID / tblClaim.ClaimUUID / tblClaim.ClaimCode | Claim can have multiple identifiers. The most important one is mapped from ClaimUUID. | mapped | |||||||
patient | tblClaim.InsureeUUID | reference to Patient resource | mapped | |||||||
outcome | tblClaim.ClaimStatus | changed from CodeableConcept to code | mapped | payment.adjustmentReason | tblClaim.Adjustment | mapped | ||||
total.category.code | 2: Claimed | 4: Checked | 8: Processed/Reviewed | 16: Valuated | based on the tblClaim.ClaimStatus | mapped | |||||||
total.amount | tblClaim.Approved / tblClaim.Valuated / tblClaim.Reinsured / tblClaim.Claimed | returning the benefit amount | mapped | |||||||
communicationRequest | tblClaim.feedbackId → tblFeedback.FeedbackUUID | reference to CommunicationRequest resource | mapped | error.code.coding.code | tblClaim.rejectionReason | mapped | error.code.text | tblClaim.rejectionReason as primary language text | to be mapped | |
item.adjudication.reason | tblClaimItems.ClaimItemStatus / tblClaimItems.Justification / tblClaimItems.RejectionReason / tblClaimServices.ClaimServiceStatus / tblClaimServices.Justification / tblClaimServices.RejectionReason | adjudication.reason contains the rejection code | mapped | item.adjudication.value | tblClaimItems.QtyProvided / tblClaimitems.QtyApproved / tblClaimServices.QtyProvided / tblClaimServices.QtyApproved | mapped | ||||
item.adjudication.amount | tblClaimItems.PriceAdjusted / tblClaimitems.PriceAdjusted / tblClaimItems.PriceApproved / tblClaimitems.PriceValuated / tblClaimServices.PriceAdjusted / tblClaimServices.PriceAdjusted / tblClaimServices.PriceApproved / tblClaimServices.PriceValuated | Monetary amount / value is taken from limitation value by default The openIMIS field considered here depends on the status of the claims. | mapped | |||||||
processNote.text | tblClaimItems.Justification / tblClaimItems.PriceOrigin / tblClaimServices.Justification / tblClaimServices.PriceOrigin | claimResponse.item.noteNumber can be used to join information about the mapped field and claim item | mapped | disposition | not mapped | |||||
created | TimeUtils.date | current date is taken on the moment of processing claim Should be mapped to ValidityTo for the date of last change? | mapped | request | reference to Claim | mapped | type | tblClaim.VisitType | mapped | |
status | tblClaim.ReviewStatus | status in [1: “Idle“, 2: “Not Selected”, 4: “Selected for Review”, 8: “Reviewed”, 16: “ByPassed”] | mapped | |||||||
requestor | tblHF.HealthFacility | reference to HealthcareService resource | mapped | |||||||
use | “claim” | mapped | “Organisation/openIMIS“ | “openIMIS” from module configuration keyMapping Status | ||||||
FHIR R4 Field | Card. | Type | openIMIS Field | Card. | Type | |||||
0..* | tblClaim.ClaimID | 1..1 | int | Claim database Primary Key | mapped | |||||
tblClaim.ClaimUUID | 1..1 | uniqueidentifier | Claim UUID | mapped | ||||||
tblClaim.ClaimCode | 1..1 | nvarchar(8) | Claim Code - unique per HF | mapped | ||||||
1..1 | tblClaim.ReviewStatus | 0..1 | tinyint | status in [1: “Idle“, 2: “Not Selected”, 4: “Selected for Review”, 8: “Reviewed”, 16: “ByPassed”] Required | mapped | |||||
1..1 | tblClaim.VisitType | 0..1 | char(1) | Required | mapped | |||||
1..1 | N/A | Always value “claim” Required | mapped | |||||||
1..1 | tblClaim.InsureeID → tblInsuree.InsureeUUID | 1..1 | uniqueidentifier | Reference to Patient resource Required | mapped | |||||
1..1 | tblClaim.ValidityFrom | 1..1 | datetime | Last update datetime. Currently set to current datetime. Required | not mapped | |||||
1..1 | N/A | Always value “Organisation/openIMIS“ “openIMIS” can be changed in module configuration Required | mapped | |||||||
0..1 | tblHF.HealthFacility | reference to HealthcareService resource | mapped | |||||||
outcome | tblClaim.ClaimStatus | changed from CodeableConcept to code | mapped | |||||||
payment.adjustmentReason | tblClaim.Adjustment | mapped | ||||||||
total | [tblClaim.Approved, tblClaim.Valuated, tblClaim.Reinsured, tblClaim.Claimed] | List of total cost per claim status. Details in category in amount. | mapped | |||||||
total.category.code | 2: Claimed | 4: Checked | 8: Processed/Reviewed | 16: Valuated | based on the tblClaim.ClaimStatus | mapped | |||||||
total.amount | tblClaim.Approved / tblClaim.Valuated / tblClaim.Reinsured / tblClaim.Claimed | returning the benefit amount | mapped | |||||||
communicationRequest | tblClaim.feedbackId → tblFeedback.FeedbackUUID | reference to CommunicationRequest resource | mapped | |||||||
error.code.coding.code | tblClaim.rejectionReason | mapped | ||||||||
error.code.text | tblClaim.rejectionReason as primary language text | to be mapped | ||||||||
item.adjudication.category | Claim.ReviewStatus value represented by the adjudication value. | 2: Claimed | 4: Checked | 8: Processed/Reviewed | 16: Valuated | mapped | |||||||
item.adjudication.reason | tblClaimItems.ClaimItemStatus / tblClaimItems.Justification / tblClaimItems.RejectionReason / tblClaimServices.ClaimServiceStatus / tblClaimServices.Justification / tblClaimServices.RejectionReason | adjudication.reason contains the rejection code | mapped | |||||||
item.adjudication.value | tblClaimItems.QtyProvided / tblClaimitems.QtyApproved / tblClaimServices.QtyProvided / tblClaimServices.QtyApproved | mapped | ||||||||
item.adjudication.amount | tblClaimItems.PriceAsked / tblClaimitems.PriceAdjusted / tblClaimItems.PriceApproved / tblClaimitems.PriceValuated / tblClaimServices.PriceAsked / tblClaimServices.PriceAdjusted / tblClaimServices.PriceApproved / tblClaimServices.PriceValuated | Monetary amount / value is taken from limitation value by default The openIMIS field considered here depends on the status of the claims. | mapped | |||||||
processNote.text | tblClaimItems.Justification / tblClaimItems.PriceOrigin / tblClaimServices.Justification / tblClaimServices.PriceOrigin | claimResponse.item.noteNumber can be used to join information about the mapped field and claim item | mapped | |||||||
disposition | not mapped | |||||||||
request | reference to Claim | mapped | ||||||||
extension.valuePeriod.billablePeriod | tblClaim.DateFrom / tblClaim.DateTo | DateFrom and DateTo are mapped to a period of time between them | mapped - mandatory | |||||||
extension.valueReference.diagnosis | tblClaim.ICDID / tblClaim.ICDID1 / tblClaim.ICDID2 / tblClaim.ICDID3 / tblClaim.ICDID4 | reference to Condition resource | mapped - mandatory |
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