FHIR R4 Resource - ClaimResponse

openIMIS tables mapped - tblClaim, tblClaimItems, tblClaimServices, tblInsuree

FHIR R4			openIMIS			Notes	Mapping Status
FHIR R4 Field	Card.	Type	openIMIS Field	Card.	Type	Notes	Mapping Status
ClaimResponse.identifier	0..*	Identifier	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
ClaimResponse.status	1..1	code	tblClaim.ReviewStatus	0..1	tinyint	status in [1: “Idle“, 2: “Not Selected”, 4: “Selected for Review”, 8: “Reviewed”, 16: “ByPassed”] Required	mapped
ClaimResponse.type	1..1	CodeableConcept	tblClaim.VisitType	0..1	char(1)	Required	mapped
ClaimResponse.use	1..1	code	N/A			Always value “claim” Required	mapped
ClaimResponse.patient	1..1	Reference(Patient)	tblClaim.InsureeID → tblInsuree.InsureeUUID	1..1	uniqueidentifier	Reference to Patient resource Required	mapped
ClaimResponse.created	1..1	dateTime	tblClaim.ValidityFrom	1..1	datetime	Last update datetime. Currently set to current datetime. Required	not mapped
ClaimResponse.insurer	1..1	Reference(Organization)	N/A			Always value “Organisation/openIMIS“ “openIMIS” can be changed in module configuration Required	mapped
ClaimResponse.requestor	0..1	Reference(Practitioner \| PractitionerRole \| Organization)	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 as Money data type	mapped
communicationRequest			tblClaim.feedbackId → tblFeedback.FeedbackUUID			reference to CommunicationRequest resource Provided only if the User has Claims.Feedback authority (111009)	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 (with adjudication.category = "rejected_reason")	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

Endpoint specification:

Example of endpoint URL:

http://localhost:8000/api_fhir_r4/ClaimResponse/

Supported HTTP operation:

POST - the operation not supported
GET - by default return list of all available resources. To fetch information about a specific object you should add the Claim UUID to URL for instance:
http://127.0.0.1:8000/api_fhir_r4/ClaimResponse/{ClaimUUID}
PUT - the operation not supported
DELETE - the operation not supported

Module configuration used by the endpoint:

Configuration key	Description	Default value
iso_date_format	iso format used for FHIR date representation	"iso_date_format": "%Y-%m-%d",
iso_datetime_format	iso format used for FHIR datetime representation	"iso_datetime_format": "%Y-%m-%dT%H:%M:%S",
R4_fhir_identifier_type_config	configuration of system and codes used to represent the specific types of identifiers	"R4_fhir_identifier_type_config":{ "system":"https://hl7.org/fhir/valueset-identifier-type.html", "fhir_code_for_imis_db_uuid_type":"UUID", "fhir_code_for_imis_db_id_type":"ACSN", "fhir_code_for_imis_chfid_type":"SB", "fhir_code_for_imis_passport_type":"PPN", "fhir_code_for_imis_facility_id_type":"FI", "fhir_code_for_imis_claim_admin_code_type":"FILL", "fhir_code_for_imis_claim_code_type":"MR", "fhir_code_for_imis_location_code_type":"LC", "fhir_code_for_imis_diagnosis_code_type":"DC", "fhir_code_for_imis_item_code_type":"IC", "fhir_code_for_imis_service_code_type":"SC" },
R4_fhir_claim_config	configuration of system and codes used to represent the specific types of claim codes	"R4_fhir_claim_config":{ "fhir_claim_information_guarantee_id_code":"guarantee_id", "fhir_claim_information_explanation_code":"explanation", "fhir_claim_item_explanation_code":"item_explanation", "fhir_claim_item_code":"item", "fhir_claim_service_code":"service", "fhir_claim_status_rejected_code":"rejected", "fhir_claim_status_entered_code":"entered", "fhir_claim_status_checked_code":"checked", "fhir_claim_status_processed_code":"processed", "fhir_claim_status_valuated_code":"evaluated", "fhir_claim_item_status_code":"claim_item_status", "fhir_claim_item_status_passed_code":"passed", "fhir_claim_item_status_rejected_code":"rejected", "fhir_claim_item_general_adjudication_code":"general", "fhir_claim_item_rejected_reason_adjudication_code":"rejected_reason", "fhir_claim_organization_code":"openIMIS" },
R4_fhir_communication_request_config	configuration of system and codes used to represent the specific codes for IMIS feedback attributes	"R4_fhir_communication_request_config":{ "fhir_care_rendered_code":"care_rendered", "fhir_payment_asked_code":"payment_asked", "fhir_drug_prescribed_code":"drug_prescribed", "fhir_drug_received_code":"drug_received", "fhir_asessment_code":"asessment" }

Example JSON Representation of Content:

As in the other resources there is an error and therefore this file is shown.

{
    "resourceType": "ClaimResponse",
    "created": "2020-07-27",
    "extension": [
        {
            "url": "billablePeriod",
            "valuePeriod": {
                "end": "2018-09-23",
                "start": "2018-09-23"
            }
        },
        {
            "url": "icd_0",
            "valueReference": {
                "reference": "Condition/A50"
            }
        }
    ],
    "id": "CFB1B205-5C7C-4F78-BDC3-824E832E0DD1",
    "identifier": [
        {
            "type": {
                "coding": [
                    {
                        "code": "UUID",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "CFB1B205-5C7C-4F78-BDC3-824E832E0DD1"
        },
        {
            "type": {
                "coding": [
                    {
                        "code": "MR",
                        "system": "https://hl7.org/fhir/valueset-identifier-type.html"
                    }
                ]
            },
            "use": "usual",
            "value": "UPDH0001"
        }
    ],
    "insurer": {
        "reference": "Organization/openIMIS"
    },
    "item": [
        {
            "adjudication": [
                {
                    "amount": {
                        "currency": "$",
                        "value": 40.0
                    },
                    "category": {
                        "coding": [
                            {
                                "code": "1"
                            }
                        ],
                        "text": "rejected"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "10"
                            }
                        ]
                    },
                    "value": 1.0
                }
            ],
            "extension": [
                {
                    "url": "Medication",
                    "valueReference": {
                        "reference": "Medication/3321fa00-a93e-4ebd-99e2-ad02827f5042"
                    }
                }
            ],
            "itemSequence": 1
        },
        {
            "adjudication": [
                {
                    "amount": {
                        "currency": "$",
                        "value": 650.0
                    },
                    "category": {
                        "coding": [
                            {
                                "code": "2"
                            }
                        ],
                        "text": "entered"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "amount": {
                        "currency": "$",
                        "value": 650.0
                    },
                    "category": {
                        "coding": [
                            {
                                "code": "4"
                            }
                        ],
                        "text": "checked"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "category": {
                        "coding": [
                            {
                                "code": "8"
                            }
                        ],
                        "text": "processed"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "category": {
                        "coding": [
                            {
                                "code": "16"
                            }
                        ],
                        "text": "valuated"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                }
            ],
            "extension": [
                {
                    "url": "ActivityDefinition",
                    "valueReference": {
                        "reference": "ActivityDefinition/90cbb870-3d86-458a-b88f-e0ce1a6cceef"
                    }
                }
            ],
            "itemSequence": 2,
            "noteNumber": [
                1
            ]
        },
        {
            "adjudication": [
                {
                    "amount": {
                        "currency": "$",
                        "value": 650.0
                    },
                    "category": {
                        "coding": [
                            {
                                "code": "2"
                            }
                        ],
                        "text": "entered"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "amount": {
                        "currency": "$",
                        "value": 650.0
                    },
                    "category": {
                        "coding": [
                            {
                                "code": "4"
                            }
                        ],
                        "text": "checked"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "category": {
                        "coding": [
                            {
                                "code": "8"
                            }
                        ],
                        "text": "processed"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                },
                {
                    "category": {
                        "coding": [
                            {
                                "code": "16"
                            }
                        ],
                        "text": "valuated"
                    },
                    "reason": {
                        "coding": [
                            {
                                "code": "0"
                            }
                        ],
                        "text": ""
                    },
                    "value": 1.0
                }
            ],
            "extension": [
                {
                    "url": "ActivityDefinition",
                    "valueReference": {
                        "reference": "ActivityDefinition/8612375f-d7ad-4237-b01a-cc9f3ca1871c"
                    }
                }
            ],
            "itemSequence": 3,
            "noteNumber": [
                2
            ]
        }
    ],
    "outcome": "valuated",
    "patient": {
        "reference": "Patient/F678F7B7-34B3-4D5E-8274-DD416080DD71"
    },
    "processNote": [
        {
            "number": 1,
            "text": "P"
        },
        {
            "number": 2,
            "text": "P"
        }
    ],
    "request": {
        "reference": "Claim/CFB1B205-5C7C-4F78-BDC3-824E832E0DD1"
    },
    "requestor": {
        "reference": "HealthcareService/9D438CCA-F1DE-4951-AE50-F138AF49E98E"
    },
    "status": "ByPassed",
    "total": [
        {
            "amount": {
                "currency": "$",
                "value": 21690.0
            },
            "category": {
                "coding": [
                    {
                        "code": "submitted",
                        "display": "Submitted Amount",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication.html"
                    }
                ],
                "text": "Claimed"
            }
        },
        {
            "amount": {
                "currency": "$",
                "value": 21000.0
            },
            "category": {
                "coding": [
                    {
                        "code": "benefit",
                        "display": "Benefit Amount",
                        "system": "http://terminology.hl7.org/CodeSystem/adjudication.html"
                    }
                ],
                "text": "Approved"
            }
        }
    ],
    "type": {
        "text": "R"
    },
    "use": "claim"
}