This page is part of the FHIR Specification (v4.4.0: R5 Preview #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 | Security Category: Patient | Compartments: Patient, Practitioner |
Detailed Descriptions for the elements in the ClaimResponse resource.
ClaimResponse | |
Element Id | ClaimResponse |
Definition | This resource provides the adjudication details from the processing of a Claim resource. |
Cardinality | 0..* |
Type | DomainResource |
Alternate Names | Remittance Advice |
ClaimResponse.identifier | |
Element Id | ClaimResponse.identifier |
Definition | A unique identifier assigned to this claim response. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Cardinality | 0..* |
Type | Identifier |
Requirements | Allows claim responses to be distinguished and referenced. |
ClaimResponse.status | |
Element Id | ClaimResponse.status |
Definition | The status of the resource instance. |
Cardinality | 1..1 |
Terminology Binding | Financial Resource Status Codes (Required) |
Type | code |
Is Modifier | true (Reason: This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) |
Requirements | Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'. |
Summary | true |
Comments | This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. |
ClaimResponse.type | |
Element Id | ClaimResponse.type |
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. |
Cardinality | 1..1 |
Terminology Binding | Claim Type Codes (Extensible) |
Type | CodeableConcept |
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. |
Summary | true |
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. |
ClaimResponse.subType | |
Element Id | ClaimResponse.subType |
Definition | A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service. |
Cardinality | 0..1 |
Terminology Binding | Example Claim SubType Codes (Example) |
Type | CodeableConcept |
Requirements | Some jurisdictions need a finer grained claim type for routing and adjudication. |
Comments | This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type. |
ClaimResponse.use | |
Element Id | ClaimResponse.use |
Definition | A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future. |
Cardinality | 1..1 |
Terminology Binding | Use (Required) |
Type | code |
Requirements | This element is required to understand the nature of the request for adjudication. |
Summary | true |
ClaimResponse.patient | |
Element Id | ClaimResponse.patient |
Definition | The party to whom the professional services and/or products have been supplied or are being considered and for whom actual for facast reimbursement is sought. |
Cardinality | 1..1 |
Type | Reference(Patient) |
Requirements | The patient must be supplied to the insurer so that confirmation of coverage and service hstory may be considered as part of the authorization and/or adjudiction. |
Summary | true |
ClaimResponse.created | |
Element Id | ClaimResponse.created |
Definition | The date this resource was created. |
Cardinality | 1..1 |
Type | dateTime |
Requirements | Need to record a timestamp for use by both the recipient and the issuer. |
Summary | true |
ClaimResponse.insurer | |
Element Id | ClaimResponse.insurer |
Definition | The party responsible for authorization, adjudication and reimbursement. |
Cardinality | 1..1 |
Type | Reference(Organization) |
Requirements | To be a valid claim, preauthorization or predetermination there must be a party who is responsible for adjudicating the contents against a policy which provides benefits for the patient. |
Summary | true |
ClaimResponse.requestor | |
Element Id | ClaimResponse.requestor |
Definition | The provider which is responsible for the claim, predetermination or preauthorization. |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole | Organization) |
Patterns | Reference(Practitioner,PractitionerRole,Organization): Common patterns = Participant |
Comments | Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below. |
ClaimResponse.request | |
Element Id | ClaimResponse.request |
Definition | Original request resource reference. |
Cardinality | 0..1 |
Type | Reference(Claim) |
Summary | true |
ClaimResponse.outcome | |
Element Id | ClaimResponse.outcome |
Definition | The outcome of the claim, predetermination, or preauthorization processing. |
Cardinality | 1..1 |
Terminology Binding | Claim Processing Codes (Required) |
Type | code |
Requirements | To advise the requestor of an overall processing outcome. |
Summary | true |
Comments | The resource may be used to indicate that: the request has been held (queued) for processing; that it has been processed and errors found (error); that no errors were found and that some of the adjudication has been undertaken (partial) or that all of the adjudication has been undertaken (complete). |
ClaimResponse.disposition | |
Element Id | ClaimResponse.disposition |
Definition | A human readable description of the status of the adjudication. |
Cardinality | 0..1 |
Type | string |
Requirements | Provided for user display. |
ClaimResponse.preAuthRef | |
Element Id | ClaimResponse.preAuthRef |
Definition | Reference from the Insurer which is used in later communications which refers to this adjudication. |
Cardinality | 0..1 |
Type | string |
Requirements | On subsequent claims, the insurer may require the provider to quote this value. |
Comments | This value is only present on preauthorization adjudications. |
ClaimResponse.preAuthPeriod | |
Element Id | ClaimResponse.preAuthPeriod |
Definition | The time frame during which this authorization is effective. |
Cardinality | 0..1 |
Type | Period |
Requirements | To convey to the provider when the authorized products and services must be supplied for the authorized adjudication to apply. |
ClaimResponse.payeeType | |
Element Id | ClaimResponse.payeeType |
Definition | Type of Party to be reimbursed: subscriber, provider, other. |
Cardinality | 0..1 |
Terminology Binding | PayeeType (Example) |
Type | CodeableConcept |
Requirements | Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber. |
ClaimResponse.item | |
Element Id | ClaimResponse.item |
Definition | A claim line. Either a simple (a product or service) or a 'group' of details which can also be a simple items or groups of sub-details. |
Cardinality | 0..* |
Requirements | The adjudication for items provided on the claim. |
ClaimResponse.item.itemSequence | |
Element Id | ClaimResponse.item.itemSequence |
Definition | A number to uniquely reference the claim item entries. |
Cardinality | 1..1 |
Type | positiveInt |
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim item. |
ClaimResponse.item.noteNumber | |
Element Id | ClaimResponse.item.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.item.adjudication | |
Element Id | ClaimResponse.item.adjudication |
Definition | If this item is a group then the values here are a summary of the adjudication of the detail items. If this item is a simple product or service then this is the result of the adjudication of this item. |
Cardinality | 1..* |
Requirements | The adjudication results conveys the insurer's assessment of the item provided in the claim under the terms of the patient's insurance coverage. |
ClaimResponse.item.adjudication.category | |
Element Id | ClaimResponse.item.adjudication.category |
Definition | A code to indicate the information type of this adjudication record. Information types may include the value submitted, maximum values or percentages allowed or payable under the plan, amounts that: the patient is responsible for in aggregate or pertaining to this item; amounts paid by other coverages; and, the benefit payable for this item. |
Cardinality | 1..1 |
Terminology Binding | Adjudication Value Codes (Example) |
Type | CodeableConcept |
Requirements | Needed to enable understanding of the context of the other information in the adjudication. |
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
ClaimResponse.item.adjudication.reason | |
Element Id | ClaimResponse.item.adjudication.reason |
Definition | A code supporting the understanding of the adjudication result and explaining variance from expected amount. |
Cardinality | 0..1 |
Terminology Binding | Adjudication Reason Codes (Example) |
Type | CodeableConcept |
Requirements | To support understanding of variance from adjudication expectations. |
Comments | For example may indicate that the funds for this benefit type have been exhausted. |
ClaimResponse.item.adjudication.amount | |
Element Id | ClaimResponse.item.adjudication.amount |
Definition | Monetary amount associated with the category. |
Cardinality | 0..1 |
Type | Money |
Requirements | Most adjuciation categories convey a monetary amount. |
Comments | For example: amount submitted, eligible amount, co-payment, and benefit payable. |
ClaimResponse.item.adjudication.value | |
Element Id | ClaimResponse.item.adjudication.value |
Definition | A non-monetary value associated with the category. Mutually exclusive to the amount element above. |
Cardinality | 0..1 |
Type | decimal |
Requirements | Some adjudication categories convey a percentage or a fixed value. |
Comments | For example: eligible percentage or co-payment percentage. |
ClaimResponse.item.detail | |
Element Id | ClaimResponse.item.detail |
Definition | A claim detail. Either a simple (a product or service) or a 'group' of sub-details which are simple items. |
Cardinality | 0..* |
Requirements | The adjudication for details provided on the claim. |
ClaimResponse.item.detail.detailSequence | |
Element Id | ClaimResponse.item.detail.detailSequence |
Definition | A number to uniquely reference the claim detail entry. |
Cardinality | 1..1 |
Type | positiveInt |
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim detail. |
ClaimResponse.item.detail.noteNumber | |
Element Id | ClaimResponse.item.detail.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.item.detail.adjudication | |
Element Id | ClaimResponse.item.detail.adjudication |
Definition | The adjudication results. |
Cardinality | 1..* |
Type | See ClaimResponse.item.adjudication |
ClaimResponse.item.detail.subDetail | |
Element Id | ClaimResponse.item.detail.subDetail |
Definition | A sub-detail adjudication of a simple product or service. |
Cardinality | 0..* |
Requirements | The adjudication for sub-details provided on the claim. |
ClaimResponse.item.detail.subDetail.subDetailSequence | |
Element Id | ClaimResponse.item.detail.subDetail.subDetailSequence |
Definition | A number to uniquely reference the claim sub-detail entry. |
Cardinality | 1..1 |
Type | positiveInt |
Requirements | Necessary to provide a mechanism to link the adjudication result to the submitted claim sub-detail. |
ClaimResponse.item.detail.subDetail.noteNumber | |
Element Id | ClaimResponse.item.detail.subDetail.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.item.detail.subDetail.adjudication | |
Element Id | ClaimResponse.item.detail.subDetail.adjudication |
Definition | The adjudication results. |
Cardinality | 0..* |
Type | See ClaimResponse.item.adjudication |
ClaimResponse.addItem | |
Element Id | ClaimResponse.addItem |
Definition | The first-tier service adjudications for payor added product or service lines. |
Cardinality | 0..* |
Requirements | Insurers may redefine the provided product or service or may package and/or decompose groups of products and services. The addItems allows the insurer to provide their line item list with linkage to the submitted items/details/sub-details. In a preauthorization the insurer may use the addItem structure to provide additional information on authorized products and services. |
ClaimResponse.addItem.itemSequence | |
Element Id | ClaimResponse.addItem.itemSequence |
Definition | Claim items which this service line is intended to replace. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides references to the claim items. |
ClaimResponse.addItem.detailSequence | |
Element Id | ClaimResponse.addItem.detailSequence |
Definition | The sequence number of the details within the claim item which this line is intended to replace. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides references to the claim details within the claim item. |
ClaimResponse.addItem.subdetailSequence | |
Element Id | ClaimResponse.addItem.subdetailSequence |
Definition | The sequence number of the sub-details within the details within the claim item which this line is intended to replace. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides references to the claim sub-details within the claim detail. |
ClaimResponse.addItem.provider | |
Element Id | ClaimResponse.addItem.provider |
Definition | The providers who are authorized for the services rendered to the patient. |
Cardinality | 0..* |
Type | Reference(Practitioner | PractitionerRole | Organization) |
Patterns | Reference(Practitioner,PractitionerRole,Organization): Common patterns = Participant |
Requirements | Insurer may provide authorization specifically to a restricted set of providers rather than an open authorization. |
ClaimResponse.addItem.productOrService | |
Element Id | ClaimResponse.addItem.productOrService |
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. |
Cardinality | 1..1 |
Terminology Binding | USCLS Codes (Example) |
Type | CodeableConcept |
Requirements | Necessary to state what was provided or done. |
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
ClaimResponse.addItem.modifier | |
Element Id | ClaimResponse.addItem.modifier |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Cardinality | 0..* |
Terminology Binding | Modifier type Codes (Example) |
Type | CodeableConcept |
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. |
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. |
ClaimResponse.addItem.programCode | |
Element Id | ClaimResponse.addItem.programCode |
Definition | Identifies the program under which this may be recovered. |
Cardinality | 0..* |
Terminology Binding | Example Program Reason Codes (Example) |
Type | CodeableConcept |
Requirements | Commonly used in in the identification of publicly provided program focused on population segments or disease classifications. |
Comments | For example: Neonatal program, child dental program or drug users recovery program. |
ClaimResponse.addItem.serviced[x] | |
Element Id | ClaimResponse.addItem.serviced[x] |
Definition | The date or dates when the service or product was supplied, performed or completed. |
Cardinality | 0..1 |
Type | date|Period |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Requirements | Needed to determine whether the service or product was provided during the term of the insurance coverage. |
ClaimResponse.addItem.location[x] | |
Element Id | ClaimResponse.addItem.location[x] |
Definition | Where the product or service was provided. |
Cardinality | 0..1 |
Terminology Binding | Example Service Place Codes (Example) |
Type | CodeableConcept|Address|Reference(Location) |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Requirements | The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount. |
ClaimResponse.addItem.quantity | |
Element Id | ClaimResponse.addItem.quantity |
Definition | The number of repetitions of a service or product. |
Cardinality | 0..1 |
Type | SimpleQuantity |
Requirements | Required when the product or service code does not convey the quantity provided. |
ClaimResponse.addItem.unitPrice | |
Element Id | ClaimResponse.addItem.unitPrice |
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
Cardinality | 0..1 |
Type | Money |
Requirements | The amount charged to the patient by the provider for a single unit. |
ClaimResponse.addItem.factor | |
Element Id | ClaimResponse.addItem.factor |
Definition | 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. |
Cardinality | 0..1 |
Type | decimal |
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. |
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
ClaimResponse.addItem.net | |
Element Id | ClaimResponse.addItem.net |
Definition | The quantity times the unit price for an additional service or product or charge. |
Cardinality | 0..1 |
Type | Money |
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. |
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
ClaimResponse.addItem.bodySite | |
Element Id | ClaimResponse.addItem.bodySite |
Definition | Physical service site on the patient (limb, tooth, etc.). |
Cardinality | 0..1 |
Terminology Binding | Oral Site Codes (Example) |
Type | CodeableConcept |
Requirements | Allows insurer to validate specific procedures. |
Comments | For example: Providing a tooth code allows an insurer to identify a provider performing a filling on a tooth that was previously removed. |
ClaimResponse.addItem.subSite | |
Element Id | ClaimResponse.addItem.subSite |
Definition | A region or surface of the bodySite, e.g. limb region or tooth surface(s). |
Cardinality | 0..* |
Terminology Binding | Surface Codes (Example) |
Type | CodeableConcept |
Requirements | Allows insurer to validate specific procedures. |
ClaimResponse.addItem.noteNumber | |
Element Id | ClaimResponse.addItem.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.addItem.adjudication | |
Element Id | ClaimResponse.addItem.adjudication |
Definition | The adjudication results. |
Cardinality | 1..* |
Type | See ClaimResponse.item.adjudication |
ClaimResponse.addItem.detail | |
Element Id | ClaimResponse.addItem.detail |
Definition | The second-tier service adjudications for payor added services. |
Cardinality | 0..* |
ClaimResponse.addItem.detail.productOrService | |
Element Id | ClaimResponse.addItem.detail.productOrService |
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. |
Cardinality | 1..1 |
Terminology Binding | USCLS Codes (Example) |
Type | CodeableConcept |
Requirements | Necessary to state what was provided or done. |
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
ClaimResponse.addItem.detail.modifier | |
Element Id | ClaimResponse.addItem.detail.modifier |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Cardinality | 0..* |
Terminology Binding | Modifier type Codes (Example) |
Type | CodeableConcept |
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. |
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. |
ClaimResponse.addItem.detail.quantity | |
Element Id | ClaimResponse.addItem.detail.quantity |
Definition | The number of repetitions of a service or product. |
Cardinality | 0..1 |
Type | SimpleQuantity |
Requirements | Required when the product or service code does not convey the quantity provided. |
ClaimResponse.addItem.detail.unitPrice | |
Element Id | ClaimResponse.addItem.detail.unitPrice |
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
Cardinality | 0..1 |
Type | Money |
Requirements | The amount charged to the patient by the provider for a single unit. |
ClaimResponse.addItem.detail.factor | |
Element Id | ClaimResponse.addItem.detail.factor |
Definition | 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. |
Cardinality | 0..1 |
Type | decimal |
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. |
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
ClaimResponse.addItem.detail.net | |
Element Id | ClaimResponse.addItem.detail.net |
Definition | The quantity times the unit price for an additional service or product or charge. |
Cardinality | 0..1 |
Type | Money |
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. |
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
ClaimResponse.addItem.detail.noteNumber | |
Element Id | ClaimResponse.addItem.detail.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.addItem.detail.adjudication | |
Element Id | ClaimResponse.addItem.detail.adjudication |
Definition | The adjudication results. |
Cardinality | 1..* |
Type | See ClaimResponse.item.adjudication |
ClaimResponse.addItem.detail.subDetail | |
Element Id | ClaimResponse.addItem.detail.subDetail |
Definition | The third-tier service adjudications for payor added services. |
Cardinality | 0..* |
ClaimResponse.addItem.detail.subDetail.productOrService | |
Element Id | ClaimResponse.addItem.detail.subDetail.productOrService |
Definition | When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item. |
Cardinality | 1..1 |
Terminology Binding | USCLS Codes (Example) |
Type | CodeableConcept |
Requirements | Necessary to state what was provided or done. |
Comments | If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'. |
ClaimResponse.addItem.detail.subDetail.modifier | |
Element Id | ClaimResponse.addItem.detail.subDetail.modifier |
Definition | Item typification or modifiers codes to convey additional context for the product or service. |
Cardinality | 0..* |
Terminology Binding | Modifier type Codes (Example) |
Type | CodeableConcept |
Requirements | To support inclusion of the item for adjudication or to charge an elevated fee. |
Comments | For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours. |
ClaimResponse.addItem.detail.subDetail.quantity | |
Element Id | ClaimResponse.addItem.detail.subDetail.quantity |
Definition | The number of repetitions of a service or product. |
Cardinality | 0..1 |
Type | SimpleQuantity |
Requirements | Required when the product or service code does not convey the quantity provided. |
ClaimResponse.addItem.detail.subDetail.unitPrice | |
Element Id | ClaimResponse.addItem.detail.subDetail.unitPrice |
Definition | If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group. |
Cardinality | 0..1 |
Type | Money |
Requirements | The amount charged to the patient by the provider for a single unit. |
ClaimResponse.addItem.detail.subDetail.factor | |
Element Id | ClaimResponse.addItem.detail.subDetail.factor |
Definition | 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. |
Cardinality | 0..1 |
Type | decimal |
Requirements | When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication. |
Comments | To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10). |
ClaimResponse.addItem.detail.subDetail.net | |
Element Id | ClaimResponse.addItem.detail.subDetail.net |
Definition | The quantity times the unit price for an additional service or product or charge. |
Cardinality | 0..1 |
Type | Money |
Requirements | Provides the total amount claimed for the group (if a grouper) or the line item. |
Comments | For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied. |
ClaimResponse.addItem.detail.subDetail.noteNumber | |
Element Id | ClaimResponse.addItem.detail.subDetail.noteNumber |
Definition | The numbers associated with notes below which apply to the adjudication of this item. |
Cardinality | 0..* |
Type | positiveInt |
Requirements | Provides a condensed manner for associating human readable descriptive explanations for adjudications on the line item. |
ClaimResponse.addItem.detail.subDetail.adjudication | |
Element Id | ClaimResponse.addItem.detail.subDetail.adjudication |
Definition | The adjudication results. |
Cardinality | 1..* |
Type | See ClaimResponse.item.adjudication |
ClaimResponse.adjudication | |
Element Id | ClaimResponse.adjudication |
Definition | The adjudication results which are presented at the header level rather than at the line-item or add-item levels. |
Cardinality | 0..* |
Type | See ClaimResponse.item.adjudication |
Requirements | Some insurers will receive line-items but provide the adjudication only at a summary or header-level. |
ClaimResponse.total | |
Element Id | ClaimResponse.total |
Definition | Categorized monetary totals for the adjudication. |
Cardinality | 0..* |
Requirements | To provide the requestor with financial totals by category for the adjudication. |
Summary | true |
Comments | Totals for amounts submitted, co-pays, benefits payable etc. |
ClaimResponse.total.category | |
Element Id | ClaimResponse.total.category |
Definition | A code to indicate the information type of this adjudication record. Information types may include: the value submitted, maximum values or percentages allowed or payable under the plan, amounts that the patient is responsible for in aggregate or pertaining to this item, amounts paid by other coverages, and the benefit payable for this item. |
Cardinality | 1..1 |
Terminology Binding | Adjudication Value Codes (Example) |
Type | CodeableConcept |
Requirements | Needed to convey the type of total provided. |
Summary | true |
Comments | For example codes indicating: Co-Pay, deductible, eligible, benefit, tax, etc. |
ClaimResponse.total.amount | |
Element Id | ClaimResponse.total.amount |
Definition | Monetary total amount associated with the category. |
Cardinality | 1..1 |
Type | Money |
Requirements | Needed to convey the total monetary amount. |
Summary | true |
ClaimResponse.payment | |
Element Id | ClaimResponse.payment |
Definition | Payment details for the adjudication of the claim. |
Cardinality | 0..1 |
Requirements | Needed to convey references to the financial instrument that has been used if payment has been made. |
ClaimResponse.payment.type | |
Element Id | ClaimResponse.payment.type |
Definition | Whether this represents partial or complete payment of the benefits payable. |
Cardinality | 1..1 |
Terminology Binding | Example Payment Type Codes (Example) |
Type | CodeableConcept |
Requirements | To advise the requestor when the insurer believes all payments to have been completed. |
ClaimResponse.payment.adjustment | |
Element Id | ClaimResponse.payment.adjustment |
Definition | Total amount of all adjustments to this payment included in this transaction which are not related to this claim's adjudication. |
Cardinality | 0..1 |
Type | Money |
Requirements | To advise the requestor of adjustments applied to the payment. |
Comments | Insurers will deduct amounts owing from the provider (adjustment), such as a prior overpayment, from the amount owing to the provider (benefits payable) when payment is made to the provider. |
ClaimResponse.payment.adjustmentReason | |
Element Id | ClaimResponse.payment.adjustmentReason |
Definition | Reason for the payment adjustment. |
Cardinality | 0..1 |
Terminology Binding | Payment Adjustment Reason Codes (Example) |
Type | CodeableConcept |
Requirements | Needed to clarify the monetary adjustment. |
ClaimResponse.payment.date | |
Element Id | ClaimResponse.payment.date |
Definition | Estimated date the payment will be issued or the actual issue date of payment. |
Cardinality | 0..1 |
Type | date |
Requirements | To advise the payee when payment can be expected. |
ClaimResponse.payment.amount | |
Element Id | ClaimResponse.payment.amount |
Definition | Benefits payable less any payment adjustment. |
Cardinality | 1..1 |
Type | Money |
Requirements | Needed to provide the actual payment amount. |
ClaimResponse.payment.identifier | |
Element Id | ClaimResponse.payment.identifier |
Definition | Issuer's unique identifier for the payment instrument. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Cardinality | 0..1 |
Type | Identifier |
Requirements | Enable the receiver to reconcile when payment received. |
Comments | For example: EFT number or check number. |
ClaimResponse.fundsReserve | |
Element Id | ClaimResponse.fundsReserve |
Definition | A code, used only on a response to a preauthorization, to indicate whether the benefits payable have been reserved and for whom. |
Cardinality | 0..1 |
Terminology Binding | FundsReserve (Example) |
Type | CodeableConcept |
Requirements | Needed to advise the submitting provider on whether the rquest for reservation of funds has been honored. |
Comments | Fund would be release by a future claim quoting the preAuthRef of this response. Examples of values include: provider, patient, none. |
ClaimResponse.formCode | |
Element Id | ClaimResponse.formCode |
Definition | A code for the form to be used for printing the content. |
Cardinality | 0..1 |
Terminology Binding | Forms (Example) |
Type | CodeableConcept |
Requirements | Needed to specify the specific form used for producing output for this response. |
Comments | May be needed to identify specific jurisdictional forms. |
ClaimResponse.form | |
Element Id | ClaimResponse.form |
Definition | The actual form, by reference or inclusion, for printing the content or an EOB. |
Cardinality | 0..1 |
Type | Attachment |
Requirements | Needed to include the specific form used for producing output for this response. |
Comments | Needed to permit insurers to include the actual form. |
ClaimResponse.processNote | |
Element Id | ClaimResponse.processNote |
Definition | A note that describes or explains adjudication results in a human readable form. |
Cardinality | 0..* |
Requirements | Provides the insurer specific textual explanations associated with the processing. |
ClaimResponse.processNote.number | |
Element Id | ClaimResponse.processNote.number |
Definition | A number to uniquely identify a note entry. |
Cardinality | 0..1 |
Type | positiveInt |
Requirements | Necessary to provide a mechanism to link from adjudications. |
ClaimResponse.processNote.type | |
Element Id | ClaimResponse.processNote.type |
Definition | The business purpose of the note text. |
Cardinality | 0..1 |
Terminology Binding | NoteType (Required) |
Type | code |
Requirements | To convey the expectation for when the text is used. |
ClaimResponse.processNote.text | |
Element Id | ClaimResponse.processNote.text |
Definition | The explanation or description associated with the processing. |
Cardinality | 1..1 |
Type | string |
Requirements | Required to provide human readable explanation. |
ClaimResponse.processNote.language | |
Element Id | ClaimResponse.processNote.language |
Definition | A code to define the language used in the text of the note. |
Cardinality | 0..1 |
Terminology Binding | Common Languages (Preferred but limited to All Languages) |
Type | CodeableConcept |
Requirements | Note text may vary from the resource defined language. |
Comments | Only required if the language is different from the resource language. |
ClaimResponse.communicationRequest | |
Element Id | ClaimResponse.communicationRequest |
Definition | Request for additional supporting or authorizing information. |
Cardinality | 0..* |
Type | Reference(CommunicationRequest) |
Requirements | Need to communicate insurer request for additional information required to support the adjudication. |
Comments | For example: professional reports, documents, images, clinical resources, or accident reports. |
ClaimResponse.insurance | |
Element Id | ClaimResponse.insurance |
Definition | Financial instruments for reimbursement for the health care products and services specified on the claim. |
Cardinality | 0..* |
Requirements | At least one insurer is required for a claim to be a claim. |
Comments | All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim. |
ClaimResponse.insurance.sequence | |
Element Id | ClaimResponse.insurance.sequence |
Definition | A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order. |
Cardinality | 1..1 |
Type | positiveInt |
Requirements | To maintain order of the coverages. |
ClaimResponse.insurance.focal | |
Element Id | ClaimResponse.insurance.focal |
Definition | A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true. |
Cardinality | 1..1 |
Type | boolean |
Requirements | To identify which coverage in the list is being used to adjudicate this claim. |
Comments | A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies. |
ClaimResponse.insurance.coverage | |
Element Id | ClaimResponse.insurance.coverage |
Definition | Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system. |
Cardinality | 1..1 |
Type | Reference(Coverage) |
Requirements | Required to allow the adjudicator to locate the correct policy and history within their information system. |
ClaimResponse.insurance.businessArrangement | |
Element Id | ClaimResponse.insurance.businessArrangement |
Definition | A business agreement number established between the provider and the insurer for special business processing purposes. |
Cardinality | 0..1 |
Type | string |
Requirements | Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication. |
ClaimResponse.insurance.claimResponse | |
Element Id | ClaimResponse.insurance.claimResponse |
Definition | The result of the adjudication of the line items for the Coverage specified in this insurance. |
Cardinality | 0..1 |
Type | Reference(ClaimResponse) |
Requirements | An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim. |
Comments | Must not be specified when 'focal=true' for this insurance. |
ClaimResponse.error | |
Element Id | ClaimResponse.error |
Definition | Errors encountered during the processing of the adjudication. |
Cardinality | 0..* |
Requirements | Need to communicate processing issues to the requestor. |
Comments | If the request contains errors then an error element should be provided and no adjudication related sections (item, addItem, or payment) should be present. |
ClaimResponse.error.itemSequence | |
Element Id | ClaimResponse.error.itemSequence |
Definition | The sequence number of the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. |
Cardinality | 0..1 |
Type | positiveInt |
Requirements | Provides references to the claim items. |
ClaimResponse.error.detailSequence | |
Element Id | ClaimResponse.error.detailSequence |
Definition | The sequence number of the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. |
Cardinality | 0..1 |
Type | positiveInt |
Requirements | Provides references to the claim details within the claim item. |
ClaimResponse.error.subDetailSequence | |
Element Id | ClaimResponse.error.subDetailSequence |
Definition | The sequence number of the sub-detail within the detail within the line item submitted which contains the error. This value is omitted when the error occurs outside of the item structure. |
Cardinality | 0..1 |
Type | positiveInt |
Requirements | Provides references to the claim sub-details within the claim detail. |
ClaimResponse.error.code | |
Element Id | ClaimResponse.error.code |
Definition | An error code, from a specified code system, which details why the claim could not be adjudicated. |
Cardinality | 1..1 |
Terminology Binding | AdjudicationError (Example) |
Type | CodeableConcept |
Requirements | Required to convey processing errors. |