STU3 Candidate

This page is part of the FHIR Specification (v1.8.0: STU 3 Draft). 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

13.2 Resource ClaimResponse - Content

Financial Management Work GroupMaturity Level: 1Compartments: Not linked to any defined compartments

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

13.2.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted Claim resource where that Claim may be 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: Claim, Re-adjudication and Reversals.

This resource is referenced by Claim and ExplanationOfBenefit

13.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse DomainResourceRemittance resource
... identifier 0..*IdentifierResponse number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... created 0..1dateTimeCreation date
... insurer 0..1Reference(Organization)Insurer
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(Claim)Id of resource triggering adjudication
... outcome 0..1CodeableConceptcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Payee Type Codes (Example)
... item 0..*BackboneElementLine items
.... sequenceLinkId 1..1positiveIntService instance
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodeableConceptAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementDetail line items
..... sequenceLinkId 1..1positiveIntService instance
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementSubdetail line items
...... sequenceLinkId 1..1positiveIntService instance
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubdetail adjudication
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptGroup, Service or Product
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptService or Product
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... error 0..*BackboneElementProcessing errors
.... sequenceLinkId 0..1positiveIntItem sequence number
.... detailSequenceLinkId 0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Extensible)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductible
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment details, if paid
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected data of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... reserved 0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage
Common Languages (Extensible but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format

UML Diagram (Legend)

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseinsurer : 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 »Original request resource referrencerequest : Reference [0..1] « Claim »Processing outcome errror, partial or complete processingoutcome : CodeableConcept [0..1] « The result of the claim processing (Strength=Example)Claim Processing ?? »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The total cost of the services reportedtotalCost : Money [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : 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 : Money [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 : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »Request for additional supporting or authorizing information, such as: documents, images or resourcescommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monetary amount associated with the codeamount : 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]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemsDetailThe type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ErrorThe 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,from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « The adjudication error codes. (Strength=Extensible)Adjudication Error + »PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datadate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identifieridentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : CodeableConcept [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Extensible)Common Languages+ »InsuranceA 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]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »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..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textnote[0..*]Financial instrument by which payment information for health careinsurance[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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept 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 -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Adjudication reason --></reason>
   <amount><!-- 0..1 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 -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail adjudication --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Service or Product --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></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 CodeableConcept Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language --></language>
 </note>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 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 -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { CodeableConcept }, // 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
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Adjudication reason
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail adjudication
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Reason for Payment adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // 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
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Adjudication reason
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ClaimResponse.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Added items details
      fhir:ClaimResponse.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ClaimResponse.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ClaimResponse.addItem.detail.service [ CodeableConcept ]; # 0..1 Service or Product
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.sequenceLinkId [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequenceLinkId [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subdetailSequenceLinkId [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Reason for Payment adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.note [ # 0..* Processing notes
    fhir:ClaimResponse.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ClaimResponse.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.note.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.note.language [ CodeableConcept ]; # 0..1 Language
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2

ClaimResponse
ClaimResponse.status added Element
ClaimResponse.insurer added Element
ClaimResponse.outcome Type changed from code to CodeableConcept
Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.payeeType Type changed from Coding to CodeableConcept
ClaimResponse.item.adjudication.category added Element
ClaimResponse.item.adjudication.reason added Element
ClaimResponse.item.adjudication.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.noteNumber added Element
ClaimResponse.item.detail.adjudication Remove BackboneElement
ClaimResponse.item.detail.subDetail.noteNumber added Element
ClaimResponse.item.detail.subDetail.adjudication Remove BackboneElement
ClaimResponse.addItem.revenue added Element
ClaimResponse.addItem.category added Element
ClaimResponse.addItem.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier added Element
ClaimResponse.addItem.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber added Element
ClaimResponse.addItem.adjudication Remove BackboneElement
ClaimResponse.addItem.detail.revenue added Element
ClaimResponse.addItem.detail.category added Element
ClaimResponse.addItem.detail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
ClaimResponse.addItem.detail.modifier added Element
ClaimResponse.addItem.detail.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.detail.noteNumber added Element
ClaimResponse.addItem.detail.adjudication Remove BackboneElement
ClaimResponse.error.code Type changed from Coding to CodeableConcept
Change binding strength from required to extensible
ClaimResponse.totalCost Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment added Element
ClaimResponse.payment.type added Element
ClaimResponse.payment.adjustment added Element
ClaimResponse.payment.adjustmentReason added Element
ClaimResponse.payment.date added Element
ClaimResponse.payment.amount added Element
ClaimResponse.payment.identifier added Element
ClaimResponse.form Type changed from Coding to CodeableConcept
ClaimResponse.note.type Type changed from Coding to CodeableConcept
ClaimResponse.note.language added Element
ClaimResponse.communicationRequest added Element
ClaimResponse.insurance added Element
ClaimResponse.insurance.sequence added Element
ClaimResponse.insurance.focal added Element
ClaimResponse.insurance.coverage added Element
ClaimResponse.insurance.businessArrangement added Element
ClaimResponse.insurance.preAuthRef added Element
ClaimResponse.insurance.claimResponse added Element
ClaimResponse.ruleset deleted
ClaimResponse.originalRuleset deleted
ClaimResponse.organization deleted
ClaimResponse.item.adjudication.code deleted
ClaimResponse.item.detail.adjudication.code deleted
ClaimResponse.item.detail.adjudication.amount deleted
ClaimResponse.item.detail.adjudication.value deleted
ClaimResponse.item.detail.subDetail.adjudication.code deleted
ClaimResponse.item.detail.subDetail.adjudication.amount deleted
ClaimResponse.item.detail.subDetail.adjudication.value deleted
ClaimResponse.addItem.noteNumberLinkId deleted
ClaimResponse.addItem.adjudication.code deleted
ClaimResponse.addItem.adjudication.amount deleted
ClaimResponse.addItem.adjudication.value deleted
ClaimResponse.addItem.detail.adjudication.code deleted
ClaimResponse.addItem.detail.adjudication.amount deleted
ClaimResponse.addItem.detail.adjudication.value deleted
ClaimResponse.paymentAdjustment deleted
ClaimResponse.paymentAdjustmentReason deleted
ClaimResponse.paymentDate deleted
ClaimResponse.paymentAmount deleted
ClaimResponse.paymentRef deleted
ClaimResponse.coverage deleted

See the Full Difference for further information

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse DomainResourceRemittance resource
... identifier 0..*IdentifierResponse number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... created 0..1dateTimeCreation date
... insurer 0..1Reference(Organization)Insurer
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(Claim)Id of resource triggering adjudication
... outcome 0..1CodeableConceptcomplete | error | partial
Claim Processing Codes (Example)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Payee Type Codes (Example)
... item 0..*BackboneElementLine items
.... sequenceLinkId 1..1positiveIntService instance
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Codes (Extensible)
..... reason 0..1CodeableConceptAdjudication reason
Adjudication Reason Codes (Extensible)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementDetail line items
..... sequenceLinkId 1..1positiveIntService instance
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail adjudication
..... subDetail 0..*BackboneElementSubdetail line items
...... sequenceLinkId 1..1positiveIntService instance
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubdetail adjudication
... addItem 0..*BackboneElementInsurer added line items
.... sequenceLinkId 0..*positiveIntService instances
.... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
.... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
.... service 0..1CodeableConceptGroup, Service or Product
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
.... detail 0..*BackboneElementAdded items details
..... revenue 0..1CodeableConceptRevenue or cost center code
Example Revenue Center Codes (Example)
..... category 0..1CodeableConceptType of service or product
Benefit SubCategory Codes (Example)
..... service 0..1CodeableConceptService or Product
USCLS Codes (Example)
..... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationAdded items detail adjudication
... error 0..*BackboneElementProcessing errors
.... sequenceLinkId 0..1positiveIntItem sequence number
.... detailSequenceLinkId 0..1positiveIntDetail sequence number
.... subdetailSequenceLinkId 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Extensible)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductible
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment details, if paid
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptReason for Payment adjustment
Payment Adjustment Reason Codes (Extensible)
.... date 0..1dateExpected data of Payment
.... amount 0..1MoneyPayment amount
.... identifier 0..1IdentifierPayment identifier
... reserved 0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Required)
... note 0..*BackboneElementProcessing notes
.... number 0..1positiveIntNote Number for this note
.... type 0..1CodeableConceptdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage
Common Languages (Extensible but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format

UML Diagram (Legend)

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseinsurer : 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 »Original request resource referrencerequest : Reference [0..1] « Claim »Processing outcome errror, partial or complete processingoutcome : CodeableConcept [0..1] « The result of the claim processing (Strength=Example)Claim Processing ?? »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Payee Type ?? »The total cost of the services reportedtotalCost : Money [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : 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 : Money [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 : CodeableConcept [0..1] « The forms codes. (Strength=Required)Form ! »Request for additional supporting or authorizing information, such as: documents, images or resourcescommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Extensible)Adjudication + »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Extensible)Adjudication Reason + »Monetary amount associated with the codeamount : 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]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersequenceLinkId : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemList of input service items which this service line is intended to replacesequenceLinkId : positiveInt [0..*]The type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemsDetailThe type of reveneu or cost center providing the product and/or servicerevenue : CodeableConcept [0..1] « Codes for the revenue or cost centers supplying the service and/or products. (Strength=Example)Example Revenue Center ?? »Health Care Service Type Codes to identify the classification of service or benefitscategory : CodeableConcept [0..1] « Benefit subcategories such as: oral-basic, major, glasses (Strength=Example)Benefit SubCategory ?? »A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ErrorThe 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,from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « The adjudication error codes. (Strength=Extensible)Adjudication Error + »PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Extensible)Payment Adjustment Reason + »Estimated payment datadate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identifieridentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : CodeableConcept [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Extensible)Common Languages+ »InsuranceA 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]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »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..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textnote[0..*]Financial instrument by which payment information for health careinsurance[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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurer --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome><!-- 0..1 CodeableConcept complete | error | partial --></outcome>
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept 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 -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Adjudication reason --></reason>
   <amount><!-- 0..1 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 -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail adjudication --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail adjudication --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[positiveInt]"/><!-- 0..* Service instances -->
  <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
  <category><!-- 0..1 CodeableConcept Type of service or product --></category>
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
  <detail>  <!-- 0..* Added items details -->
   <revenue><!-- 0..1 CodeableConcept Revenue or cost center code --></revenue>
   <category><!-- 0..1 CodeableConcept Type of service or product --></category>
   <service><!-- 0..1 CodeableConcept Service or Product --></service>
   <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></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 CodeableConcept Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Reason for Payment adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payment amount --></amount>
  <identifier><!-- 0..1 Identifier Payment identifier --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 CodeableConcept display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language --></language>
 </note>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 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 -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : { CodeableConcept }, // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { CodeableConcept }, // 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
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Adjudication reason
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail adjudication
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail adjudication
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : ["<positiveInt>"], // Service instances
    "revenue" : { CodeableConcept }, // Revenue or cost center code
    "category" : { CodeableConcept }, // Type of service or product
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication
    "detail" : [{ // Added items details
      "revenue" : { CodeableConcept }, // Revenue or cost center code
      "category" : { CodeableConcept }, // Type of service or product
      "service" : { CodeableConcept }, // Service or Product
      "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
      "fee" : { Money }, // Professional fee or Product charge
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : "<positiveInt>", // Item sequence number
    "detailSequenceLinkId" : "<positiveInt>", // Detail sequence number
    "subdetailSequenceLinkId" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Reason for Payment adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payment amount
    "identifier" : { Identifier } // Payment identifier
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : "<positiveInt>", // Note Number for this note
    "type" : { CodeableConcept }, // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // 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
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurer
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ CodeableConcept ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Adjudication reason
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail adjudication
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.sequenceLinkId [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail adjudication
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.sequenceLinkId [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
    fhir:ClaimResponse.addItem.category [ CodeableConcept ]; # 0..1 Type of service or product
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
    fhir:ClaimResponse.addItem.detail [ # 0..* Added items details
      fhir:ClaimResponse.addItem.detail.revenue [ CodeableConcept ]; # 0..1 Revenue or cost center code
      fhir:ClaimResponse.addItem.detail.category [ CodeableConcept ]; # 0..1 Type of service or product
      fhir:ClaimResponse.addItem.detail.service [ CodeableConcept ]; # 0..1 Service or Product
      fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
      fhir:ClaimResponse.addItem.detail.fee [ Money ]; # 0..1 Professional fee or Product charge
      fhir:ClaimResponse.addItem.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.addItem.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication
    ], ...;
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.sequenceLinkId [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequenceLinkId [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subdetailSequenceLinkId [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Reason for Payment adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payment amount
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Payment identifier
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.note [ # 0..* Processing notes
    fhir:ClaimResponse.note.number [ positiveInt ]; # 0..1 Note Number for this note
    fhir:ClaimResponse.note.type [ CodeableConcept ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.note.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.note.language [ CodeableConcept ]; # 0..1 Language
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2

ClaimResponse
ClaimResponse.status added Element
ClaimResponse.insurer added Element
ClaimResponse.outcome Type changed from code to CodeableConcept
Remove Binding http://hl7.org/fhir/ValueSet/remittance-outcome (required)
ClaimResponse.payeeType Type changed from Coding to CodeableConcept
ClaimResponse.item.adjudication.category added Element
ClaimResponse.item.adjudication.reason added Element
ClaimResponse.item.adjudication.amount Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.noteNumber added Element
ClaimResponse.item.detail.adjudication Remove BackboneElement
ClaimResponse.item.detail.subDetail.noteNumber added Element
ClaimResponse.item.detail.subDetail.adjudication Remove BackboneElement
ClaimResponse.addItem.revenue added Element
ClaimResponse.addItem.category added Element
ClaimResponse.addItem.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier added Element
ClaimResponse.addItem.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber added Element
ClaimResponse.addItem.adjudication Remove BackboneElement
ClaimResponse.addItem.detail.revenue added Element
ClaimResponse.addItem.detail.category added Element
ClaimResponse.addItem.detail.service Min Cardinality changed from 1 to 0
Type changed from Coding to CodeableConcept
ClaimResponse.addItem.detail.modifier added Element
ClaimResponse.addItem.detail.fee Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.detail.noteNumber added Element
ClaimResponse.addItem.detail.adjudication Remove BackboneElement
ClaimResponse.error.code Type changed from Coding to CodeableConcept
Change binding strength from required to extensible
ClaimResponse.totalCost Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment added Element
ClaimResponse.payment.type added Element
ClaimResponse.payment.adjustment added Element
ClaimResponse.payment.adjustmentReason added Element
ClaimResponse.payment.date added Element
ClaimResponse.payment.amount added Element
ClaimResponse.payment.identifier added Element
ClaimResponse.form Type changed from Coding to CodeableConcept
ClaimResponse.note.type Type changed from Coding to CodeableConcept
ClaimResponse.note.language added Element
ClaimResponse.communicationRequest added Element
ClaimResponse.insurance added Element
ClaimResponse.insurance.sequence added Element
ClaimResponse.insurance.focal added Element
ClaimResponse.insurance.coverage added Element
ClaimResponse.insurance.businessArrangement added Element
ClaimResponse.insurance.preAuthRef added Element
ClaimResponse.insurance.claimResponse added Element
ClaimResponse.ruleset deleted
ClaimResponse.originalRuleset deleted
ClaimResponse.organization deleted
ClaimResponse.item.adjudication.code deleted
ClaimResponse.item.detail.adjudication.code deleted
ClaimResponse.item.detail.adjudication.amount deleted
ClaimResponse.item.detail.adjudication.value deleted
ClaimResponse.item.detail.subDetail.adjudication.code deleted
ClaimResponse.item.detail.subDetail.adjudication.amount deleted
ClaimResponse.item.detail.subDetail.adjudication.value deleted
ClaimResponse.addItem.noteNumberLinkId deleted
ClaimResponse.addItem.adjudication.code deleted
ClaimResponse.addItem.adjudication.amount deleted
ClaimResponse.addItem.adjudication.value deleted
ClaimResponse.addItem.detail.adjudication.code deleted
ClaimResponse.addItem.detail.adjudication.amount deleted
ClaimResponse.addItem.detail.adjudication.value deleted
ClaimResponse.paymentAdjustment deleted
ClaimResponse.paymentAdjustmentReason deleted
ClaimResponse.paymentDate deleted
ClaimResponse.paymentAmount deleted
ClaimResponse.paymentRef deleted
ClaimResponse.coverage deleted

See the Full Difference for further information

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron (for ) + JSON Schema, ShEx (for Turtle), JSON-LD (for RDF as JSON-LD),

13.2.2.1 Terminology Bindings

PathDefinitionTypeReference
ClaimResponse.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
ClaimResponse.outcome The result of the claim processingExampleClaim Processing Codes
ClaimResponse.payeeType A code for the party to be reimbursed.ExamplePayee Type Codes
ClaimResponse.item.adjudication.category The adjudication codes.ExtensibleAdjudication Codes
ClaimResponse.item.adjudication.reason The adjudication reason codes.ExtensibleAdjudication Reason Codes
ClaimResponse.addItem.revenue
ClaimResponse.addItem.detail.revenue 		Codes for the revenue or cost centers supplying the service and/or products.ExampleExample Revenue Center Codes
ClaimResponse.addItem.category
ClaimResponse.addItem.detail.category 		Benefit subcategories such as: oral-basic, major, glassesExampleBenefit SubCategory Codes
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codes.ExampleUSCLS Codes
ClaimResponse.addItem.modifier
ClaimResponse.addItem.detail.modifier 		Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
ClaimResponse.error.code The adjudication error codes.ExtensibleAdjudication Error Codes
ClaimResponse.payment.type The type (partial, complete) of the paymentExampleExample Payment Type Codes
ClaimResponse.payment.adjustmentReason Payment Adjustment reason codes.ExtensiblePayment Adjustment 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.note.language A human language.Extensible, but limited to All LanguagesCommon Languages

13.2.3 Search Parameters

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

NameTypeDescriptionPathsIn Common
createddateThe creation dateClaimResponse.created
dispositionstringThe contents of the disposition messageClaimResponse.disposition
identifiertokenThe identity of the claimresponseClaimResponse.identifier
insurerreferenceThe organization who generated this resourceClaimResponse.insurer
(Organization)
outcometokenThe processing outcomeClaimResponse.outcome
payment-datedateThe expected paymentDateClaimResponse.payment.date
requestreferenceThe claim referenceClaimResponse.request
(Claim)