Name Flags Card. Type Description & Constraints doco
. . 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

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