GAO Ballot Package

This page is part of the FHIR Specification (v1.1.0: STU 3 Ballot 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

This is a frozen snapshot of the FHIR specification created for the purpose of balloting the GAO implementation Guide. It includes draft changes that may be part of the future DSTU 2.1 release but further change is expected. Readers should focus solely on the GAO implementation content, and FHIR DSTU 2 for other purposes.

7.2 Resource ClaimResponse - Content

Financial Management Work GroupMaturity Level: 0Compartments: Not linked to any defined compartments

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

7.2.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted disciplineClaim which is the functional corollary of a Claim, Pre-Determination or a Pre-Authorization.

This is the adjudicated response to a Claim, Pre-determination or Pre-Authorization. The strength of the payment aspect of the response is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made, for Pre-Authorization and Pre-Determination no payment will actually be made however funds may be reserved to settle a claim submitted later. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource is the response for the submission of: OralHealthClaim, VisionClaim etc. and Reversals.

Todo

This resource is referenced by claim

7.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse ΣDomainResourceRemittance resource
... identifier Σ0..*IdentifierResponse number
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization Σ0..1Reference(Organization)Insurer
... requestProvider Σ0..1Reference(Practitioner)Responsible practitioner
... requestOrganization Σ0..1Reference(Organization)Responsible organization
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... payeeType Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
... item Σ0..*BackboneElementLine items
.... sequenceLinkId Σ1..1positiveIntService instance
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementDetail line items
..... sequenceLinkId Σ1..1positiveIntService instance
..... adjudication Σ0..*BackboneElementDetail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
..... subDetail Σ0..*BackboneElementSubdetail line items
...... sequenceLinkId Σ1..1positiveIntService instance
...... adjudication Σ0..*BackboneElementSubdetail adjudication
....... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monetary value
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
... error Σ0..*BackboneElementProcessing errors
.... sequenceLinkId Σ0..1positiveIntItem sequence number
.... detailSequenceLinkId Σ0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId Σ0..1positiveIntSubdetail sequence number
.... code Σ1..1CodingError code detailing processing issues
Adjudication Error Codes (Required)
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductible
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanatory text
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)

doco Documentation for this format

UML Diagram

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referrencerequest : Reference [0..1] « Claim »The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The total cost of the services reportedtotalCost : Quantity(Money) [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : Quantity(Money) [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)totalBenefit : Quantity(Money) [0..1]Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Quantity(Money) [0..1]Reason for the payment adjustmentpaymentAdjustmentReason : Coding [0..1] « Adjustment reason codes. (Strength=Extensible)Adjustment Reason + »Estimated payment datapaymentDate : date [0..1]Payable less any payment adjustmentpaymentAmount : Quantity(Money) [0..1]Payment identifierpaymentRef : Identifier [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »ItemsA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ItemAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA service line numbersequenceLinkId : positiveInt [1..1]DetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]SubDetailA service line numbersequenceLinkId : positiveInt [1..1]SubdetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]A list of note references to the notes provided belownoteNumberLinkId : positiveInt [0..*]AddedItemAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]AddedItemDetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ErrorsThe sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewheresequenceLinkId : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequenceLinkId : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubdetailSequenceLinkId : positiveInt [0..1]An error code,froma specified code system, which details why the claim could not be adjudicatedcode : Coding [1..1] « The error codes for adjudication processing. (Strength=Required)Adjudication Error ! »NotesAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The third tier service adjudications for submitted servicessubDetail[0..*]The second tier service adjudications for submitted servicesdetail[0..*]The first tier service adjudications for submitted servicesitem[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The second tier service adjudications for payor added servicesdetail[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]Mutually exclusive with Services Provided (Item)error[0..*]Note textnote[0..*]Financial instrument by which payment information for health carecoverage[0..*]

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monetary value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductible
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanatory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse ΣDomainResourceRemittance resource
... identifier Σ0..*IdentifierResponse number
... request Σ0..1Reference(Claim)Id of resource triggering adjudication
... ruleset Σ0..1CodingResource version
Ruleset Codes (Example)
... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)
... created Σ0..1dateTimeCreation date
... organization Σ0..1Reference(Organization)Insurer
... requestProvider Σ0..1Reference(Practitioner)Responsible practitioner
... requestOrganization Σ0..1Reference(Organization)Responsible organization
... outcome Σ0..1codecomplete | error
RemittanceOutcome (Required)
... disposition Σ0..1stringDisposition Message
... payeeType Σ0..1CodingParty to be paid any benefits payable
Payee Type Codes (Example)
... item Σ0..*BackboneElementLine items
.... sequenceLinkId Σ1..1positiveIntService instance
.... noteNumber Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdjudication details
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementDetail line items
..... sequenceLinkId Σ1..1positiveIntService instance
..... adjudication Σ0..*BackboneElementDetail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
..... subDetail Σ0..*BackboneElementSubdetail line items
...... sequenceLinkId Σ1..1positiveIntService instance
...... adjudication Σ0..*BackboneElementSubdetail adjudication
....... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
....... amount Σ0..1MoneyMonetary amount
....... value Σ0..1decimalNon-monetary value
... addItem Σ0..*BackboneElementInsurer added line items
.... sequenceLinkId Σ0..*positiveIntService instances
.... service Σ1..1CodingGroup, Service or Product
USCLS Codes (Example)
.... fee Σ0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId Σ0..*positiveIntList of note numbers which apply
.... adjudication Σ0..*BackboneElementAdded items adjudication
..... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... amount Σ0..1MoneyMonetary amount
..... value Σ0..1decimalNon-monetary value
.... detail Σ0..*BackboneElementAdded items details
..... service Σ1..1CodingService or Product
USCLS Codes (Example)
..... fee Σ0..1MoneyProfessional fee or Product charge
..... adjudication Σ0..*BackboneElementAdded items detail adjudication
...... code Σ1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
...... amount Σ0..1MoneyMonetary amount
...... value Σ0..1decimalNon-monetary value
... error Σ0..*BackboneElementProcessing errors
.... sequenceLinkId Σ0..1positiveIntItem sequence number
.... detailSequenceLinkId Σ0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId Σ0..1positiveIntSubdetail sequence number
.... code Σ1..1CodingError code detailing processing issues
Adjudication Error Codes (Required)
... totalCost Σ0..1MoneyTotal Cost of service from the Claim
... unallocDeductable Σ0..1MoneyUnallocated deductible
... totalBenefit Σ0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment Σ0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason Σ0..1CodingReason for Payment adjustment
Adjustment Reason Codes (Extensible)
... paymentDate Σ0..1dateExpected data of Payment
... paymentAmount Σ0..1MoneyPayment amount
... paymentRef Σ0..1IdentifierPayment identifier
... reserved Σ0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form Σ0..1CodingPrinted Form Identifier
Form Codes (Required)
... note Σ0..*BackboneElementProcessing notes
.... number Σ0..1positiveIntNote Number for this note
.... type Σ0..1Codingdisplay | print | printoper
NoteType (Required)
.... text Σ0..1stringNote explanatory text
... coverage Σ0..*BackboneElementInsurance or medical plan
.... sequence Σ1..1positiveIntService instance identifier
.... focal Σ1..1booleanIs the focal Coverage
.... coverage Σ1..1Reference(Coverage)Insurance information
.... businessArrangement Σ0..1stringBusiness agreement
.... relationship Σ1..1CodingPatient relationship to subscriber
Surface Codes (Example)
.... preAuthRef Σ0..*stringPre-Authorization/Determination Reference
.... claimResponse Σ0..1Reference(ClaimResponse)Adjudication results
.... originalRuleset Σ0..1CodingOriginal version
Ruleset Codes (Example)

doco Documentation for this format

UML Diagram

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]Original request resource referrencerequest : Reference [0..1] « Claim »The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseorganization : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Transaction status: error, completeoutcome : code [0..1] « The outcome of the processing. (Strength=Required)RemittanceOutcome! »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : Coding [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The total cost of the services reportedtotalCost : Quantity(Money) [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : Quantity(Money) [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)totalBenefit : Quantity(Money) [0..1]Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Quantity(Money) [0..1]Reason for the payment adjustmentpaymentAdjustmentReason : Coding [0..1] « Adjustment reason codes. (Strength=Extensible)Adjustment Reason + »Estimated payment datapaymentDate : date [0..1]Payable less any payment adjustmentpaymentAmount : Quantity(Money) [0..1]Payment identifierpaymentRef : Identifier [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : Coding [0..1] « The forms codes. (Strength=Required)Form ! »ItemsA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ItemAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA service line numbersequenceLinkId : positiveInt [1..1]DetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]SubDetailA service line numbersequenceLinkId : positiveInt [1..1]SubdetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]A list of note references to the notes provided belownoteNumberLinkId : positiveInt [0..*]AddedItemAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding [1..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »The fee charged for the professional service or product.fee : Quantity(Money) [0..1]AddedItemDetailAdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccode : Coding [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Monetary amount associated with the codeamount : Quantity(Money) [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ErrorsThe sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewheresequenceLinkId : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequenceLinkId : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubdetailSequenceLinkId : positiveInt [0..1]An error code,froma specified code system, which details why the claim could not be adjudicatedcode : Coding [1..1] « The error codes for adjudication processing. (Strength=Required)Adjudication Error ! »NotesAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : Coding [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]CoverageA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]The relationship of the patient to the subscriberrelationship : Coding [1..1] « The code for the relationship of the patient to the subscriber. (Strength=Example)Surface ?? »A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding [0..1] « The static and dynamic model to which contents conform, which may be business version or standard/version. (Strength=Example)Ruleset ?? »The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The third tier service adjudications for submitted servicessubDetail[0..*]The second tier service adjudications for submitted servicesdetail[0..*]The first tier service adjudications for submitted servicesitem[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The second tier service adjudications for payor added servicesdetail[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]Mutually exclusive with Services Provided (Item)error[0..*]Note textnote[0..*]Financial instrument by which payment information for health carecoverage[0..*]

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Quantity(Money) Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Quantity(Money) Monetary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Quantity(Money) Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Quantity(Money) Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Quantity(Money) Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Quantity(Money) Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Quantity(Money) Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Quantity(Money) }, // Monetary amount
          "value" : <decimal> // Non-monetary value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Quantity(Money) }, // Professional fee or Product charge
    "noteNumberLinkId" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Quantity(Money) }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Quantity(Money) }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Quantity(Money) }, // Monetary amount
        "value" : <decimal> // Non-monetary value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Quantity(Money) }, // Total Cost of service from the Claim
  "unallocDeductable" : { Quantity(Money) }, // Unallocated deductible
  "totalBenefit" : { Quantity(Money) }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Quantity(Money) }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Quantity(Money) }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanatory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.2.2.1 Terminology Bindings

PathDefinitionTypeReference
ClaimResponse.ruleset
ClaimResponse.originalRuleset
ClaimResponse.coverage.originalRuleset 		The static and dynamic model to which contents conform, which may be business version or standard/version.ExampleRuleset Codes
ClaimResponse.outcome The outcome of the processing.RequiredRemittanceOutcome
ClaimResponse.payeeType A code for the party to be reimbursed.ExamplePayee Type Codes
ClaimResponse.item.adjudication.code
ClaimResponse.item.detail.adjudication.code
ClaimResponse.item.detail.subDetail.adjudication.code
ClaimResponse.addItem.adjudication.code
ClaimResponse.addItem.detail.adjudication.code 		The adjudication codes.ExtensibleAdjudication Codes
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codes.ExampleUSCLS Codes
ClaimResponse.error.code The error codes for adjudication processing.RequiredAdjudication Error Codes
ClaimResponse.paymentAdjustmentReason Adjustment reason codes.ExtensibleAdjustment Reason Codes
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
ClaimResponse.form The forms codes.RequiredForm Codes
ClaimResponse.note.type The presentation types of notes.RequiredNoteType
ClaimResponse.coverage.relationship The code for the relationship of the patient to the subscriber.ExampleSurface Codes

7.2.3 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
identifiertokenThe identity of the insurerClaimResponse.identifier