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

The response business identifier.

The status of the resource instance.

This element is labeled as a modifier because the status contains the code cancelled and entered-in-error that mark the response as not currently valid.

The category of claim, e.g, oral, pharmacy, vision, institutional, professional.

Affects which fields and value sets are used.

A finer grained suite of claim subtype codes which may convey Inpatient vs Outpatient and/or a specialty service. In the US the CMS Bill Type.

This may contain the local bill type codes such as the US UB-04 bill type code.

A claim, a list of completed goods and services; a preauthorization, a list or proposed goods and services; or a predetermination, a set of goods and services being considered, for which insurer adjudication is sought.

Patient Resource.

The date when this resource was created.

The Insurer who produced this adjudicated response.

The practitioner who is responsible for the services rendered to the patient.

Original request resource reference.

Transaction: error, complete, partial processing.

A description of the status of the adjudication.

A list of references from the Insurer to which these services pertain.

To provide any pre-determination or prior authorization reference.

Party to be reimbursed: Subscriber, provider, other.

The first-tier service adjudications for submitted services.

A service line number.

A list of note references to the notes provided below.

The adjudication results.

Code indicating: Co-Pay, deductible, eligible, benefit, tax, etc.

Adjudication reason such as limit reached.

Monetary amount associated with the code.

A non-monetary value for example a percentage. Mutually exclusive to the amount element above.

The second-tier service adjudications for submitted services.

A service line number.

A list of note references to the notes provided below.

The adjudication results.

The third-tier service adjudications for submitted services.

A service line number.

A list of note references to the notes provided below.

The adjudication results.

The first-tier service adjudications for payor added services.

List of input service items which this service line is intended to replace.

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 Addition.

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 Addition.

The providers who are authorized for the services rendered to the patient.

A code to indicate the Professional Service or Product supplied.

Item typification or modifiers codes, e.g. 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 hours.

May impact on adjudication.

For programs which require reason codes for the inclusion or covering of this billed item under the program or sub-program.

The date or dates when the service or product was supplied, performed or completed.

Where the service was provided.

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

Physical service site on the patient (limb, tooth, etc.).

A region or surface of the site, e.g. limb region or tooth surface(s).

A list of note references to the notes provided below.

The adjudication results.

The second-tier service adjudications for payor added services.

A code to indicate the Professional Service or Product supplied.

Item typification or modifiers codes, e.g. 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 hours.

May impact on adjudication.

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

A list of note references to the notes provided below.

The adjudication results.

The third-tier service adjudications for payor added services.

A code to indicate the Professional Service or Product supplied.

Item typification or modifiers codes, e.g. 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 hours.

May impact on adjudication.

The number of repetitions of a service or product.

If the item is a node then this is the fee for the product or service, otherwise this is the total of the fees for the children of the group.

A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

If a fee is present the associated product/service code must be present.

The quantity times the unit price for an additional service or product or charge. For example, the formula: unit Quantity * unit Price (Cost per Point) * factor Number * points = net Amount. Quantity, factor and points are assumed to be 1 if not supplied.

If a fee is present the associated product/service code must be present.

A list of note references to the notes provided below.

The adjudication results.

Mutually exclusive with Services Provided (Item).

The sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhere.

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 Addition.

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 Addition.

An error code, from a specified code system, which details why the claim could not be adjudicated.

Totals for amounts submitted, co-pays, benefits payable etc.

Code indicating: Submitted, Co-Pay, deductible, eligible, benefit, tax, etc.

Monitory amount associated with the code.

Payment details for the claim if the claim has been paid.

Whether this represents partial or complete payment of the claim.

Adjustment to the payment of this transaction which is not related to adjudication of this transaction.

Reason for the payment adjustment.

Estimated payment data.

Payable less any payment adjustment.

Payment identifier.

Status of funds reservation (For provider, for Patient, None).

The form to be used for printing the content.

Note text.

An integer associated with each note which may be referred to from each service line item.

The note purpose: Print/Display.

The note text.

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 English.

Request for additional supporting or authorizing information, such as: documents, images or resources.

Financial instrument by which payment information for health care.

Health care programs and insurers are significant payors of health service costs.

A service line item.

To maintain order of the coverages.

The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicated.

To identify which coverage is being adjudicated.

Reference to the program or plan identification, underwriter or payor.

Need to identify the issuer to target for processing and for coordination of benefit processing.

The contract number of a business agreement which describes the terms and conditions.

The Coverages adjudication details.

Used by downstream payers to determine what balance remains and the net payable.