This page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). 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
Financial Management Work Group | Maturity Level: 2 | Trial Use | Compartments: Patient, Practitioner |
This resource provides the adjudication details from the processing of a Claim resource.
The ClaimResponse resource provides application level adjudication results, or an application level error, 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.
The ClaimResponse may have been created by interpreting the corresponding Claim resource as a request for payment (the oldest sense of a claim), a request for preauthorization or a request for predetermination. These interpretations are described at the Claim resource. It is possible for the consumer of the ClaimResponse resource to know the manner in which the Claim resource was processed by checking the Claim.use code.
Where the producer of the ClaimResponse resource interpreted the Claim as a traditional claim, the contents of the ClaimResponse includes information that the producer of the ClaimResponse intends to pay. The actual payment, however, is conveyed separately, perhaps through an eletronic funds transfer protocol outside the domain of FHIR or possibly by a paper check.
However, when the producer of the ClaimResponse interpreted the Claim as request for preauthorization or predetermination, the ClaimResponse does not imply that such a payment is pending. Actual payment would only follow the interpretation fo a Claim resource as a traditional claim.
This resource is referenced by Claim, itself, DeviceRequest, ExplanationOfBenefit, MedicationRequest, ServiceRequest and Task
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | TU | DomainResource | ClaimResponse resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | 0..* | Identifier | Response number | |
status | ?!Σ | 0..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) |
type | 0..1 | CodeableConcept | Type or discipline Claim Type Codes (Extensible) | |
subType | 0..1 | CodeableConcept | Finer grained claim type information Example Claim SubType Codes (Example) | |
use | Σ | 0..1 | code | claim | preauthorization | predetermination Use (Required) |
patient | 0..1 | Reference(Patient) | The subject of the Products and Services | |
created | 0..1 | dateTime | Creation date | |
insurer | 0..1 | Reference(Organization) | Insurance issuing organization | |
requestProvider | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Responsible practitioner | |
request | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
outcome | 0..1 | code | queued | complete | error | partial Claim Processing Codes (Required) | |
disposition | 0..1 | string | Disposition Message | |
preAuthRef | 0..1 | string | Pre-Authorization/Determination Reference | |
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable PayeeType (Example) | |
item | 0..* | BackboneElement | Line items | |
itemSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | BackboneElement | Adjudication details | |
category | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
reason | 0..1 | CodeableConcept | Explanation of Adjudication outcome Adjudication Reason Codes (Example) | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monetary value | |
detail | 0..* | BackboneElement | Detail line items | |
detailSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Subdetail line items | |
subDetailSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Subdetail level adjudication details | |
addItem | 0..* | BackboneElement | Insurer added line items | |
itemSequence | 0..* | positiveInt | Service instances | |
detailSequence | 0..* | positiveInt | Detail sequence number | |
subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
serviced[x] | 0..1 | Date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
bodySite | 0..1 | CodeableConcept | Service Location Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Service Sub-location Surface Codes (Example) | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items adjudication | |
detail | 0..* | BackboneElement | Insurer added line items | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
subDetail | 0..* | BackboneElement | Insurer added line items | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
error | 0..* | BackboneElement | Processing errors | |
itemSequence | 0..1 | positiveInt | Item sequence number | |
detailSequence | 0..1 | positiveInt | Detail sequence number | |
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |
code | 1..1 | CodeableConcept | Error code detailing processing issues AdjudicationError (Example) | |
total | 0..* | BackboneElement | Adjudication totals | |
category | 1..1 | CodeableConcept | Adjudication category such as submitted, co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
amount | 1..1 | Money | Monetary amount | |
payment | 0..1 | BackboneElement | Payment Details | |
type | 0..1 | CodeableConcept | Partial or Complete Example Payment Type Codes (Example) | |
adjustment | 0..1 | Money | Payment adjustment for non-Claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Payment Adjustment Reason Codes (Example) | |
date | 0..1 | date | Expected data of Payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Identifier of the payment instrument | |
reserved | 0..1 | Coding | Funds reserved status FundsReserve (Example) | |
form | 0..1 | CodeableConcept | Printed Form Identifier Forms (Example) | |
processNote | 0..* | BackboneElement | Processing notes | |
number | 0..1 | positiveInt | Sequence Number for this note | |
type | 0..1 | code | display | print | printoper NoteType (Required) | |
text | 0..1 | string | Note explanatory text | |
language | 0..1 | CodeableConcept | Language if different from the resource Language (Preferred but limited to All Languages) | |
communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |
insurance | 0..* | BackboneElement | Insurance or medical plan | |
sequence | 1..1 | positiveInt | Service instance identifier | |
focal | 1..1 | boolean | Is the focal Coverage | |
coverage | 1..1 | Reference(Coverage) | Insurance information | |
businessArrangement | 0..1 | string | Business agreement | |
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
Documentation for this format |
UML Diagram (Legend)
XML Template
<ClaimResponse xmlns="http://hl7.org/fhir"> <!-- 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 --> <type><!-- 0..1 CodeableConcept Type or discipline --></type> <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType> <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination --> <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient> <created value="[dateTime]"/><!-- 0..1 Creation date --> <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer> <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider> <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request> <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial --> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference --> <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType> <item> <!-- 0..* Line items --> <itemSequence 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 Explanation of Adjudication outcome --></reason> <amount><!-- 0..1 Money Monetary amount --></amount> <value value="[decimal]"/><!-- 0..1 Non-monetary value --> </adjudication> <detail> <!-- 0..* Detail line items --> <detailSequence 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 level adjudication details --></adjudication> <subDetail> <!-- 0..* Subdetail line items --> <subDetailSequence 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 level adjudication details --></adjudication> </subDetail> </detail> </item> <addItem> <!-- 0..* Insurer added line items --> <itemSequence value="[positiveInt]"/><!-- 0..* Service instances --> <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number --> <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number --> <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite> <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication> <detail> <!-- 0..* Insurer added line items --> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication> <subDetail> <!-- 0..* Insurer added line items --> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication> </subDetail> </detail> </addItem> <error> <!-- 0..* Processing errors --> <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number --> <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number --> <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number --> <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code> </error> <total> <!-- 0..* Adjudication totals --> <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category> <amount><!-- 1..1 Money Monetary amount --></amount> </total> <payment> <!-- 0..1 Payment Details --> <type><!-- 0..1 CodeableConcept Partial or Complete --></type> <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment> <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason> <date value="[date]"/><!-- 0..1 Expected data of Payment --> <amount><!-- 0..1 Money Payable amount after adjustment --></amount> <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier> </payment> <reserved><!-- 0..1 Coding Funds reserved status --></reserved> <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form> <processNote> <!-- 0..* Processing notes --> <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note --> <type value="[code]"/><!-- 0..1 display | print | printoper --> <text value="[string]"/><!-- 0..1 Note explanatory text --> <language><!-- 0..1 CodeableConcept Language if different from the resource --></language> </processNote> <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 --> <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse> </insurance> </ClaimResponse>
JSON Template
{ "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 "type" : { CodeableConcept }, // Type or discipline "subType" : { CodeableConcept }, // Finer grained claim type information "use" : "<code>", // claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // The subject of the Products and Services "created" : "<dateTime>", // Creation date "insurer" : { Reference(Organization) }, // Insurance issuing organization "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner "request" : { Reference(Claim) }, // Id of resource triggering adjudication "outcome" : "<code>", // queued | complete | error | partial "disposition" : "<string>", // Disposition Message "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable "item" : [{ // Line items "itemSequence" : "<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 }, // Explanation of Adjudication outcome "amount" : { Money }, // Monetary amount "value" : <decimal> // Non-monetary value }], "detail" : [{ // Detail line items "detailSequence" : "<positiveInt>", // R! Service instance "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details "subDetail" : [{ // Subdetail line items "subDetailSequence" : "<positiveInt>", // R! Service instance "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details }] }] }], "addItem" : [{ // Insurer added line items "itemSequence" : ["<positiveInt>"], // Service instances "detailSequence" : ["<positiveInt>"], // Detail sequence number "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion // serviced[x]: Date or dates of Service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "bodySite" : { CodeableConcept }, // Service Location "subSite" : [{ CodeableConcept }], // Service Sub-location "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication "detail" : [{ // Insurer added line items "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication "subDetail" : [{ // Insurer added line items "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication }] }] }], "error" : [{ // Processing errors "itemSequence" : "<positiveInt>", // Item sequence number "detailSequence" : "<positiveInt>", // Detail sequence number "subDetailSequence" : "<positiveInt>", // Subdetail sequence number "code" : { CodeableConcept } // R! Error code detailing processing issues }], "total" : [{ // Adjudication totals "category" : { CodeableConcept }, // R! Adjudication category such as submitted, co-pay, eligible, benefit, etc. "amount" : { Money } // R! Monetary amount }], "payment" : { // Payment Details "type" : { CodeableConcept }, // Partial or Complete "adjustment" : { Money }, // Payment adjustment for non-Claim issues "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment "date" : "<date>", // Expected data of Payment "amount" : { Money }, // Payable amount after adjustment "identifier" : { Identifier } // Identifier of the payment instrument }, "reserved" : { Coding }, // Funds reserved status "form" : { CodeableConcept }, // Printed Form Identifier "processNote" : [{ // Processing notes "number" : "<positiveInt>", // Sequence Number for this note "type" : "<code>", // display | print | printoper "text" : "<string>", // Note explanatory text "language" : { CodeableConcept } // Language if different from the resource }], "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 "claimResponse" : { Reference(ClaimResponse) } // Adjudication results }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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.type [ CodeableConcept ]; # 0..1 Type or discipline fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information fhir:ClaimResponse.use [ code ]; # 0..1 claim | preauthorization | predetermination fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization fhir:ClaimResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication fhir:ClaimResponse.outcome [ code ]; # 0..1 queued | complete | error | partial fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable fhir:ClaimResponse.item [ # 0..* Line items fhir:ClaimResponse.item.itemSequence [ 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 Explanation of Adjudication outcome 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.detailSequence [ 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 level adjudication details fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ 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 level adjudication details ], ...; ], ...; ], ...; fhir:ClaimResponse.addItem [ # 0..* Insurer added line items fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers fhir:ClaimResponse.addItem.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of Service. One of these 2 fhir:ClaimResponse.addItem.servicedDate [ date ] fhir:ClaimResponse.addItem.servicedPeriod [ Period ] # ClaimResponse.addItem.location[x] : 0..1 Place of service. One of these 3 fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ] fhir:ClaimResponse.addItem.locationAddress [ Address ] fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ] fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Service Location fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location 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..* Insurer added line items fhir:ClaimResponse.addItem.detail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost 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.addItem.detail.subDetail [ # 0..* Insurer added line items fhir:ClaimResponse.addItem.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication ], ...; ], ...; ], ...; fhir:ClaimResponse.error [ # 0..* Processing errors fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues ], ...; fhir:ClaimResponse.total [ # 0..* Adjudication totals fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Adjudication category such as submitted, co-pay, eligible, benefit, etc. fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Monetary amount ], ...; fhir:ClaimResponse.payment [ # 0..1 Payment Details 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 Explanation for the non-claim adjustment fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument ]; fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier fhir:ClaimResponse.processNote [ # 0..* Processing notes fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource ], ...; 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.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results ], ...; ]
Changes since R3
ClaimResponse | |
ClaimResponse.type |
|
ClaimResponse.subType |
|
ClaimResponse.use |
|
ClaimResponse.requestProvider |
|
ClaimResponse.outcome |
|
ClaimResponse.preAuthRef |
|
ClaimResponse.item.itemSequence |
|
ClaimResponse.item.detail.detailSequence |
|
ClaimResponse.item.detail.subDetail.subDetailSequence |
|
ClaimResponse.addItem.itemSequence |
|
ClaimResponse.addItem.detailSequence |
|
ClaimResponse.addItem.subdetailSequence |
|
ClaimResponse.addItem.provider |
|
ClaimResponse.addItem.billcode |
|
ClaimResponse.addItem.programCode |
|
ClaimResponse.addItem.serviced[x] |
|
ClaimResponse.addItem.location[x] |
|
ClaimResponse.addItem.quantity |
|
ClaimResponse.addItem.unitPrice |
|
ClaimResponse.addItem.factor |
|
ClaimResponse.addItem.net |
|
ClaimResponse.addItem.bodySite |
|
ClaimResponse.addItem.subSite |
|
ClaimResponse.addItem.detail.billcode |
|
ClaimResponse.addItem.detail.quantity |
|
ClaimResponse.addItem.detail.unitPrice |
|
ClaimResponse.addItem.detail.factor |
|
ClaimResponse.addItem.detail.net |
|
ClaimResponse.addItem.detail.subDetail |
|
ClaimResponse.addItem.detail.subDetail.billcode |
|
ClaimResponse.addItem.detail.subDetail.modifier |
|
ClaimResponse.addItem.detail.subDetail.quantity |
|
ClaimResponse.addItem.detail.subDetail.unitPrice |
|
ClaimResponse.addItem.detail.subDetail.factor |
|
ClaimResponse.addItem.detail.subDetail.net |
|
ClaimResponse.addItem.detail.subDetail.noteNumber |
|
ClaimResponse.addItem.detail.subDetail.adjudication |
|
ClaimResponse.error.itemSequence |
|
ClaimResponse.error.detailSequence |
|
ClaimResponse.error.subDetailSequence |
|
ClaimResponse.total |
|
ClaimResponse.total.category |
|
ClaimResponse.total.amount |
|
ClaimResponse.processNote.type |
|
ClaimResponse.processNote.language |
|
ClaimResponse.requestOrganization |
|
ClaimResponse.item.sequenceLinkId |
|
ClaimResponse.item.detail.sequenceLinkId |
|
ClaimResponse.item.detail.subDetail.sequenceLinkId |
|
ClaimResponse.addItem.sequenceLinkId |
|
ClaimResponse.addItem.revenue |
|
ClaimResponse.addItem.category |
|
ClaimResponse.addItem.service |
|
ClaimResponse.addItem.fee |
|
ClaimResponse.addItem.detail.revenue |
|
ClaimResponse.addItem.detail.category |
|
ClaimResponse.addItem.detail.service |
|
ClaimResponse.addItem.detail.fee |
|
ClaimResponse.error.sequenceLinkId |
|
ClaimResponse.error.detailSequenceLinkId |
|
ClaimResponse.error.subdetailSequenceLinkId |
|
ClaimResponse.totalCost |
|
ClaimResponse.unallocDeductable |
|
ClaimResponse.totalBenefit |
|
ClaimResponse.insurance.preAuthRef |
|
See the Full Difference for further information
This analysis is available as XML or JSON.
See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)
Structure
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
ClaimResponse | TU | DomainResource | ClaimResponse resource Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | 0..* | Identifier | Response number | |
status | ?!Σ | 0..1 | code | active | cancelled | draft | entered-in-error Financial Resource Status Codes (Required) |
type | 0..1 | CodeableConcept | Type or discipline Claim Type Codes (Extensible) | |
subType | 0..1 | CodeableConcept | Finer grained claim type information Example Claim SubType Codes (Example) | |
use | Σ | 0..1 | code | claim | preauthorization | predetermination Use (Required) |
patient | 0..1 | Reference(Patient) | The subject of the Products and Services | |
created | 0..1 | dateTime | Creation date | |
insurer | 0..1 | Reference(Organization) | Insurance issuing organization | |
requestProvider | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Responsible practitioner | |
request | 0..1 | Reference(Claim) | Id of resource triggering adjudication | |
outcome | 0..1 | code | queued | complete | error | partial Claim Processing Codes (Required) | |
disposition | 0..1 | string | Disposition Message | |
preAuthRef | 0..1 | string | Pre-Authorization/Determination Reference | |
payeeType | 0..1 | CodeableConcept | Party to be paid any benefits payable PayeeType (Example) | |
item | 0..* | BackboneElement | Line items | |
itemSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | BackboneElement | Adjudication details | |
category | 1..1 | CodeableConcept | Adjudication category such as co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
reason | 0..1 | CodeableConcept | Explanation of Adjudication outcome Adjudication Reason Codes (Example) | |
amount | 0..1 | Money | Monetary amount | |
value | 0..1 | decimal | Non-monetary value | |
detail | 0..* | BackboneElement | Detail line items | |
detailSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Detail level adjudication details | |
subDetail | 0..* | BackboneElement | Subdetail line items | |
subDetailSequence | 1..1 | positiveInt | Service instance | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Subdetail level adjudication details | |
addItem | 0..* | BackboneElement | Insurer added line items | |
itemSequence | 0..* | positiveInt | Service instances | |
detailSequence | 0..* | positiveInt | Detail sequence number | |
subdetailSequence | 0..* | positiveInt | Subdetail sequence number | |
provider | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
programCode | 0..* | CodeableConcept | Program specific reason for item inclusion Example Program Reason Codes (Example) | |
serviced[x] | 0..1 | Date or dates of Service | ||
servicedDate | date | |||
servicedPeriod | Period | |||
location[x] | 0..1 | Place of service Example Service Place Codes (Example) | ||
locationCodeableConcept | CodeableConcept | |||
locationAddress | Address | |||
locationReference | Reference(Location) | |||
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
bodySite | 0..1 | CodeableConcept | Service Location Oral Site Codes (Example) | |
subSite | 0..* | CodeableConcept | Service Sub-location Surface Codes (Example) | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items adjudication | |
detail | 0..* | BackboneElement | Insurer added line items | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
subDetail | 0..* | BackboneElement | Insurer added line items | |
billcode | 0..1 | CodeableConcept | Group, Service or Product USCLS Codes (Example) | |
modifier | 0..* | CodeableConcept | Service/Product billing modifiers Modifier type Codes (Example) | |
quantity | 0..1 | SimpleQuantity | Count of Products or Services | |
unitPrice | 0..1 | Money | Fee, charge or cost per point | |
factor | 0..1 | decimal | Price scaling factor | |
net | 0..1 | Money | Total item cost | |
noteNumber | 0..* | positiveInt | List of note numbers which apply | |
adjudication | 0..* | see adjudication | Added items detail adjudication | |
error | 0..* | BackboneElement | Processing errors | |
itemSequence | 0..1 | positiveInt | Item sequence number | |
detailSequence | 0..1 | positiveInt | Detail sequence number | |
subDetailSequence | 0..1 | positiveInt | Subdetail sequence number | |
code | 1..1 | CodeableConcept | Error code detailing processing issues AdjudicationError (Example) | |
total | 0..* | BackboneElement | Adjudication totals | |
category | 1..1 | CodeableConcept | Adjudication category such as submitted, co-pay, eligible, benefit, etc. Adjudication Value Codes (Example) | |
amount | 1..1 | Money | Monetary amount | |
payment | 0..1 | BackboneElement | Payment Details | |
type | 0..1 | CodeableConcept | Partial or Complete Example Payment Type Codes (Example) | |
adjustment | 0..1 | Money | Payment adjustment for non-Claim issues | |
adjustmentReason | 0..1 | CodeableConcept | Explanation for the non-claim adjustment Payment Adjustment Reason Codes (Example) | |
date | 0..1 | date | Expected data of Payment | |
amount | 0..1 | Money | Payable amount after adjustment | |
identifier | 0..1 | Identifier | Identifier of the payment instrument | |
reserved | 0..1 | Coding | Funds reserved status FundsReserve (Example) | |
form | 0..1 | CodeableConcept | Printed Form Identifier Forms (Example) | |
processNote | 0..* | BackboneElement | Processing notes | |
number | 0..1 | positiveInt | Sequence Number for this note | |
type | 0..1 | code | display | print | printoper NoteType (Required) | |
text | 0..1 | string | Note explanatory text | |
language | 0..1 | CodeableConcept | Language if different from the resource Language (Preferred but limited to All Languages) | |
communicationRequest | 0..* | Reference(CommunicationRequest) | Request for additional information | |
insurance | 0..* | BackboneElement | Insurance or medical plan | |
sequence | 1..1 | positiveInt | Service instance identifier | |
focal | 1..1 | boolean | Is the focal Coverage | |
coverage | 1..1 | Reference(Coverage) | Insurance information | |
businessArrangement | 0..1 | string | Business agreement | |
claimResponse | 0..1 | Reference(ClaimResponse) | Adjudication results | |
Documentation for this format |
XML Template
<ClaimResponse xmlns="http://hl7.org/fhir"> <!-- 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 --> <type><!-- 0..1 CodeableConcept Type or discipline --></type> <subType><!-- 0..1 CodeableConcept Finer grained claim type information --></subType> <use value="[code]"/><!-- 0..1 claim | preauthorization | predetermination --> <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient> <created value="[dateTime]"/><!-- 0..1 Creation date --> <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer> <requestProvider><!-- 0..1 Reference(Practitioner|PractitionerRole|Organization) Responsible practitioner --></requestProvider> <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request> <outcome value="[code]"/><!-- 0..1 queued | complete | error | partial --> <disposition value="[string]"/><!-- 0..1 Disposition Message --> <preAuthRef value="[string]"/><!-- 0..1 Pre-Authorization/Determination Reference --> <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType> <item> <!-- 0..* Line items --> <itemSequence 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 Explanation of Adjudication outcome --></reason> <amount><!-- 0..1 Money Monetary amount --></amount> <value value="[decimal]"/><!-- 0..1 Non-monetary value --> </adjudication> <detail> <!-- 0..* Detail line items --> <detailSequence 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 level adjudication details --></adjudication> <subDetail> <!-- 0..* Subdetail line items --> <subDetailSequence 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 level adjudication details --></adjudication> </subDetail> </detail> </item> <addItem> <!-- 0..* Insurer added line items --> <itemSequence value="[positiveInt]"/><!-- 0..* Service instances --> <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number --> <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number --> <provider><!-- 0..* Reference(Practitioner|PractitionerRole|Organization) Authorized providers --></provider> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <programCode><!-- 0..* CodeableConcept Program specific reason for item inclusion --></programCode> <serviced[x]><!-- 0..1 date|Period Date or dates of Service --></serviced[x]> <location[x]><!-- 0..1 CodeableConcept|Address|Reference(Location) Place of service --></location[x]> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <bodySite><!-- 0..1 CodeableConcept Service Location --></bodySite> <subSite><!-- 0..* CodeableConcept Service Sub-location --></subSite> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication> <detail> <!-- 0..* Insurer added line items --> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication> <subDetail> <!-- 0..* Insurer added line items --> <billcode><!-- 0..1 CodeableConcept Group, Service or Product --></billcode> <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier> <quantity><!-- 0..1 Quantity(SimpleQuantity) Count of Products or Services --></quantity> <unitPrice><!-- 0..1 Money Fee, charge or cost per point --></unitPrice> <factor value="[decimal]"/><!-- 0..1 Price scaling factor --> <net><!-- 0..1 Money Total item cost --></net> <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply --> <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items detail adjudication --></adjudication> </subDetail> </detail> </addItem> <error> <!-- 0..* Processing errors --> <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number --> <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number --> <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number --> <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code> </error> <total> <!-- 0..* Adjudication totals --> <category><!-- 1..1 CodeableConcept Adjudication category such as submitted, co-pay, eligible, benefit, etc. --></category> <amount><!-- 1..1 Money Monetary amount --></amount> </total> <payment> <!-- 0..1 Payment Details --> <type><!-- 0..1 CodeableConcept Partial or Complete --></type> <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment> <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason> <date value="[date]"/><!-- 0..1 Expected data of Payment --> <amount><!-- 0..1 Money Payable amount after adjustment --></amount> <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier> </payment> <reserved><!-- 0..1 Coding Funds reserved status --></reserved> <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form> <processNote> <!-- 0..* Processing notes --> <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note --> <type value="[code]"/><!-- 0..1 display | print | printoper --> <text value="[string]"/><!-- 0..1 Note explanatory text --> <language><!-- 0..1 CodeableConcept Language if different from the resource --></language> </processNote> <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 --> <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse> </insurance> </ClaimResponse>
JSON Template
{ "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 "type" : { CodeableConcept }, // Type or discipline "subType" : { CodeableConcept }, // Finer grained claim type information "use" : "<code>", // claim | preauthorization | predetermination "patient" : { Reference(Patient) }, // The subject of the Products and Services "created" : "<dateTime>", // Creation date "insurer" : { Reference(Organization) }, // Insurance issuing organization "requestProvider" : { Reference(Practitioner|PractitionerRole|Organization) }, // Responsible practitioner "request" : { Reference(Claim) }, // Id of resource triggering adjudication "outcome" : "<code>", // queued | complete | error | partial "disposition" : "<string>", // Disposition Message "preAuthRef" : "<string>", // Pre-Authorization/Determination Reference "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable "item" : [{ // Line items "itemSequence" : "<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 }, // Explanation of Adjudication outcome "amount" : { Money }, // Monetary amount "value" : <decimal> // Non-monetary value }], "detail" : [{ // Detail line items "detailSequence" : "<positiveInt>", // R! Service instance "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details "subDetail" : [{ // Subdetail line items "subDetailSequence" : "<positiveInt>", // R! Service instance "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details }] }] }], "addItem" : [{ // Insurer added line items "itemSequence" : ["<positiveInt>"], // Service instances "detailSequence" : ["<positiveInt>"], // Detail sequence number "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number "provider" : [{ Reference(Practitioner|PractitionerRole|Organization) }], // Authorized providers "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "programCode" : [{ CodeableConcept }], // Program specific reason for item inclusion // serviced[x]: Date or dates of Service. One of these 2: "servicedDate" : "<date>", "servicedPeriod" : { Period }, // location[x]: Place of service. One of these 3: "locationCodeableConcept" : { CodeableConcept }, "locationAddress" : { Address }, "locationReference" : { Reference(Location) }, "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "bodySite" : { CodeableConcept }, // Service Location "subSite" : [{ CodeableConcept }], // Service Sub-location "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items adjudication "detail" : [{ // Insurer added line items "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Added items detail adjudication "subDetail" : [{ // Insurer added line items "billcode" : { CodeableConcept }, // Group, Service or Product "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers "quantity" : { Quantity(SimpleQuantity) }, // Count of Products or Services "unitPrice" : { Money }, // Fee, charge or cost per point "factor" : <decimal>, // Price scaling factor "net" : { Money }, // Total item cost "noteNumber" : ["<positiveInt>"], // List of note numbers which apply "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items detail adjudication }] }] }], "error" : [{ // Processing errors "itemSequence" : "<positiveInt>", // Item sequence number "detailSequence" : "<positiveInt>", // Detail sequence number "subDetailSequence" : "<positiveInt>", // Subdetail sequence number "code" : { CodeableConcept } // R! Error code detailing processing issues }], "total" : [{ // Adjudication totals "category" : { CodeableConcept }, // R! Adjudication category such as submitted, co-pay, eligible, benefit, etc. "amount" : { Money } // R! Monetary amount }], "payment" : { // Payment Details "type" : { CodeableConcept }, // Partial or Complete "adjustment" : { Money }, // Payment adjustment for non-Claim issues "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment "date" : "<date>", // Expected data of Payment "amount" : { Money }, // Payable amount after adjustment "identifier" : { Identifier } // Identifier of the payment instrument }, "reserved" : { Coding }, // Funds reserved status "form" : { CodeableConcept }, // Printed Form Identifier "processNote" : [{ // Processing notes "number" : "<positiveInt>", // Sequence Number for this note "type" : "<code>", // display | print | printoper "text" : "<string>", // Note explanatory text "language" : { CodeableConcept } // Language if different from the resource }], "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 "claimResponse" : { Reference(ClaimResponse) } // Adjudication results }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ 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.type [ CodeableConcept ]; # 0..1 Type or discipline fhir:ClaimResponse.subType [ CodeableConcept ]; # 0..1 Finer grained claim type information fhir:ClaimResponse.use [ code ]; # 0..1 claim | preauthorization | predetermination fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization fhir:ClaimResponse.requestProvider [ Reference(Practitioner|PractitionerRole|Organization) ]; # 0..1 Responsible practitioner fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication fhir:ClaimResponse.outcome [ code ]; # 0..1 queued | complete | error | partial fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message fhir:ClaimResponse.preAuthRef [ string ]; # 0..1 Pre-Authorization/Determination Reference fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable fhir:ClaimResponse.item [ # 0..* Line items fhir:ClaimResponse.item.itemSequence [ 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 Explanation of Adjudication outcome 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.detailSequence [ 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 level adjudication details fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ 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 level adjudication details ], ...; ], ...; ], ...; fhir:ClaimResponse.addItem [ # 0..* Insurer added line items fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number fhir:ClaimResponse.addItem.provider [ Reference(Practitioner|PractitionerRole|Organization) ], ... ; # 0..* Authorized providers fhir:ClaimResponse.addItem.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.programCode [ CodeableConcept ], ... ; # 0..* Program specific reason for item inclusion # ClaimResponse.addItem.serviced[x] : 0..1 Date or dates of Service. One of these 2 fhir:ClaimResponse.addItem.servicedDate [ date ] fhir:ClaimResponse.addItem.servicedPeriod [ Period ] # ClaimResponse.addItem.location[x] : 0..1 Place of service. One of these 3 fhir:ClaimResponse.addItem.locationCodeableConcept [ CodeableConcept ] fhir:ClaimResponse.addItem.locationAddress [ Address ] fhir:ClaimResponse.addItem.locationReference [ Reference(Location) ] fhir:ClaimResponse.addItem.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.net [ Money ]; # 0..1 Total item cost fhir:ClaimResponse.addItem.bodySite [ CodeableConcept ]; # 0..1 Service Location fhir:ClaimResponse.addItem.subSite [ CodeableConcept ], ... ; # 0..* Service Sub-location 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..* Insurer added line items fhir:ClaimResponse.addItem.detail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.detail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.detail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.detail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.detail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.detail.net [ Money ]; # 0..1 Total item cost 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.addItem.detail.subDetail [ # 0..* Insurer added line items fhir:ClaimResponse.addItem.detail.subDetail.billcode [ CodeableConcept ]; # 0..1 Group, Service or Product fhir:ClaimResponse.addItem.detail.subDetail.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers fhir:ClaimResponse.addItem.detail.subDetail.quantity [ Quantity(SimpleQuantity) ]; # 0..1 Count of Products or Services fhir:ClaimResponse.addItem.detail.subDetail.unitPrice [ Money ]; # 0..1 Fee, charge or cost per point fhir:ClaimResponse.addItem.detail.subDetail.factor [ decimal ]; # 0..1 Price scaling factor fhir:ClaimResponse.addItem.detail.subDetail.net [ Money ]; # 0..1 Total item cost fhir:ClaimResponse.addItem.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply fhir:ClaimResponse.addItem.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items detail adjudication ], ...; ], ...; ], ...; fhir:ClaimResponse.error [ # 0..* Processing errors fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues ], ...; fhir:ClaimResponse.total [ # 0..* Adjudication totals fhir:ClaimResponse.total.category [ CodeableConcept ]; # 1..1 Adjudication category such as submitted, co-pay, eligible, benefit, etc. fhir:ClaimResponse.total.amount [ Money ]; # 1..1 Monetary amount ], ...; fhir:ClaimResponse.payment [ # 0..1 Payment Details 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 Explanation for the non-claim adjustment fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument ]; fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier fhir:ClaimResponse.processNote [ # 0..* Processing notes fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource ], ...; 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.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results ], ...; ]
Changes since Release 3
ClaimResponse | |
ClaimResponse.type |
|
ClaimResponse.subType |
|
ClaimResponse.use |
|
ClaimResponse.requestProvider |
|
ClaimResponse.outcome |
|
ClaimResponse.preAuthRef |
|
ClaimResponse.item.itemSequence |
|
ClaimResponse.item.detail.detailSequence |
|
ClaimResponse.item.detail.subDetail.subDetailSequence |
|
ClaimResponse.addItem.itemSequence |
|
ClaimResponse.addItem.detailSequence |
|
ClaimResponse.addItem.subdetailSequence |
|
ClaimResponse.addItem.provider |
|
ClaimResponse.addItem.billcode |
|
ClaimResponse.addItem.programCode |
|
ClaimResponse.addItem.serviced[x] |
|
ClaimResponse.addItem.location[x] |
|
ClaimResponse.addItem.quantity |
|
ClaimResponse.addItem.unitPrice |
|
ClaimResponse.addItem.factor |
|
ClaimResponse.addItem.net |
|
ClaimResponse.addItem.bodySite |
|
ClaimResponse.addItem.subSite |
|
ClaimResponse.addItem.detail.billcode |
|
ClaimResponse.addItem.detail.quantity |
|
ClaimResponse.addItem.detail.unitPrice |
|
ClaimResponse.addItem.detail.factor |
|
ClaimResponse.addItem.detail.net |
|
ClaimResponse.addItem.detail.subDetail |
|
ClaimResponse.addItem.detail.subDetail.billcode |
|
ClaimResponse.addItem.detail.subDetail.modifier |
|
ClaimResponse.addItem.detail.subDetail.quantity |
|
ClaimResponse.addItem.detail.subDetail.unitPrice |
|
ClaimResponse.addItem.detail.subDetail.factor |
|
ClaimResponse.addItem.detail.subDetail.net |
|
ClaimResponse.addItem.detail.subDetail.noteNumber |
|
ClaimResponse.addItem.detail.subDetail.adjudication |
|
ClaimResponse.error.itemSequence |
|
ClaimResponse.error.detailSequence |
|
ClaimResponse.error.subDetailSequence |
|
ClaimResponse.total |
|
ClaimResponse.total.category |
|
ClaimResponse.total.amount |
|
ClaimResponse.processNote.type |
|
ClaimResponse.processNote.language |
|
ClaimResponse.requestOrganization |
|
ClaimResponse.item.sequenceLinkId |
|
ClaimResponse.item.detail.sequenceLinkId |
|
ClaimResponse.item.detail.subDetail.sequenceLinkId |
|
ClaimResponse.addItem.sequenceLinkId |
|
ClaimResponse.addItem.revenue |
|
ClaimResponse.addItem.category |
|
ClaimResponse.addItem.service |
|
ClaimResponse.addItem.fee |
|
ClaimResponse.addItem.detail.revenue |
|
ClaimResponse.addItem.detail.category |
|
ClaimResponse.addItem.detail.service |
|
ClaimResponse.addItem.detail.fee |
|
ClaimResponse.error.sequenceLinkId |
|
ClaimResponse.error.detailSequenceLinkId |
|
ClaimResponse.error.subdetailSequenceLinkId |
|
ClaimResponse.totalCost |
|
ClaimResponse.unallocDeductable |
|
ClaimResponse.totalBenefit |
|
ClaimResponse.insurance.preAuthRef |
|
See the Full Difference for further information
This analysis is available as XML or JSON.
See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)
See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis
Path | Definition | Type | Reference |
---|---|---|---|
ClaimResponse.status | A code specifying the state of the resource instance. | Required | FinancialResourceStatusCodes |
ClaimResponse.type | The type or discipline-style of the claim. | Extensible | ClaimTypeCodes |
ClaimResponse.subType | A more granulat claim typecode. | Example | ExampleClaimSubTypeCodes |
ClaimResponse.use | Claim, preauthorization, predetermination. | Required | Use |
ClaimResponse.outcome | The result of the claim processing. | Required | ClaimProcessingCodes |
ClaimResponse.payeeType | A code for the party to be reimbursed. | Example | Claim Payee Type Codes |
ClaimResponse.item.adjudication.category ClaimResponse.total.category | The adjudication codes. | Example | AdjudicationValueCodes |
ClaimResponse.item.adjudication.reason | The adjudication reason codes. | Example | AdjudicationReasonCodes |
ClaimResponse.addItem.billcode ClaimResponse.addItem.detail.billcode ClaimResponse.addItem.detail.subDetail.billcode | Allowable service and product codes. | Example | USCLSCodes |
ClaimResponse.addItem.modifier ClaimResponse.addItem.detail.modifier ClaimResponse.addItem.detail.subDetail.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. | Example | ModifierTypeCodes |
ClaimResponse.addItem.programCode | Program specific reason codes. | Example | ExampleProgramReasonCodes |
ClaimResponse.addItem.location[x] | Place of service: pharmacy,school, prison, etc. | Example | ExampleServicePlaceCodes |
ClaimResponse.addItem.bodySite | The code for the teeth, quadrant, sextant and arch. | Example | OralSiteCodes |
ClaimResponse.addItem.subSite | The code for the tooth surface and surface combinations. | Example | SurfaceCodes |
ClaimResponse.error.code | The adjudication error codes. | Example | Adjudication Error Codes |
ClaimResponse.payment.type | The type (partial, complete) of the payment. | Example | ExamplePaymentTypeCodes |
ClaimResponse.payment.adjustmentReason | Payment Adjustment reason codes. | Example | PaymentAdjustmentReasonCodes |
ClaimResponse.reserved | For whom funds are to be reserved: (Patient, Provider, None). | Example | Funds Reservation Codes |
ClaimResponse.form | The forms codes. | Example | Form Codes |
ClaimResponse.processNote.type | The presentation types of notes. | Required | NoteType |
ClaimResponse.processNote.language | A human language. | Preferred, but limited to All Languages | Common Languages |
Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.
Name | Type | Description | Expression | In Common |
created | date | The creation date | ClaimResponse.created | |
disposition | string | The contents of the disposition message | ClaimResponse.disposition | |
identifier | token | The identity of the ClaimResponse | ClaimResponse.identifier | |
insurer | reference | The organization who generated this resource | ClaimResponse.insurer (Organization) | |
outcome | token | The processing outcome | ClaimResponse.outcome | |
patient | reference | The subject of care | ClaimResponse.patient (Patient) | |
payment-date | date | The expected payment date | ClaimResponse.payment.date | |
request | reference | The claim reference | ClaimResponse.request (Claim) | |
request-provider | reference | The Provider of the claim | ClaimResponse.requestProvider (Practitioner, Organization, PractitionerRole) | |
status | token | The status of the ClaimResponse | ClaimResponse.status |