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7.2 Resource ClaimResponse - Content

This resource maintained by the Financial Management Work Group

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

7.2.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted disciplineClaim 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: OralHealthClaim, VisionClaim etc. and Reversals.

Todo

This resource is referenced by [Claim]

7.2.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse DomainResourceRemittance resource
... identifier 0..*IdentifierResponse number
... request 0..1ClaimId of resource triggering adjudication
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodingParty to be paid any benefits payable
PayeeType (Example)
... item 0..*ElementLine items
.... sequenceLinkId 1..1integerService instance
.... noteNumber 0..*integerList of note numbers which apply
.... adjudication 0..*ElementAdjudication details
..... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
..... amount 0..1MoneyMonitary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*ElementDetail line items
..... sequenceLinkId 1..1integerService instance
..... adjudication 0..*ElementDetail adjudication
...... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
...... amount 0..1MoneyMonitary amount
...... value 0..1decimalNon-monitory value
..... subDetail 0..*ElementSubdetail line items
...... sequenceLinkId 1..1integerService instance
...... adjudication 0..*ElementSubdetail adjudication
....... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
....... amount 0..1MoneyMonitary amount
....... value 0..1decimalNon-monitory value
... addItem 0..*ElementInsurer added line items
.... sequenceLinkId 0..*integerService instances
.... service 1..1CodingGroup, Service or Product
ServiceProduct (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId 0..*integerList of note numbers which apply
.... adjudication 0..*ElementAdded items adjudication
..... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
..... amount 0..1MoneyMonitary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*ElementAdded items details
..... service 1..1CodingService or Product
ServiceProduct (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... adjudication 0..*ElementAdded items detail adjudication
...... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
...... amount 0..1MoneyMonitary amount
...... value 0..1decimalNon-monitory value
... error 0..*ElementProcessing errors
.... sequenceLinkId 0..1integerItem sequence number
.... detailSequenceLinkId 0..1integerDetail sequence number
.... subdetailSequenceLinkId 0..1integerSubdetail sequence number
.... code 1..1CodingError code detailing processing issues
AdjudicationError (Required)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment 0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason 0..1CodingReason for Payment adjustment
AdjustmentReason (Required)
... paymentDate 0..1dateExpected data of Payment
... paymentAmount 0..1MoneyPayment amount
... paymentRef 0..1IdentifierPayment identifier
... reserved 0..1CodingFunds reserved status
FundsReserve (Example)
... form 0..1CodingPrinted Form Identifier
Forms (Required)
... note 0..*ElementProcessing notes
.... number 0..1integerNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
... coverage 0..*ElementInsurance or medical plan
.... sequence 1..1integerService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Relationship (Example)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1ClaimResponseAdjudication results
.... originalRuleset 0..1CodingOriginal version
Ruleset (Example)

UML Diagram

ClaimResponse (DomainResource)The Response Business Identifieridentifier : Identifier 0..*Original request resource referrencerequest : Reference(Claim) 0..1The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1The Insurer who produced this adjudicated responseorganization : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientrequestOrganization : Reference(Organization) 0..1Transaction status: error, completeoutcome : code 0..1 « The outcome of the processing.RemittanceOutcome »A description of the status of the adjudicationdisposition : string 0..1Party to be reimbursed: Subscriber, provider, otherpayeeType : Coding 0..1 « (A code for the party to be reimbursed.PayeeType) »The total cost of the services reportedtotalCost : Money 0..1The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : Money 0..1Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)totalBenefit : Money 0..1Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Money 0..1Reason for the payment adjustmentpaymentAdjustmentReason : Coding 0..1 « Adjustment reason codesAdjustmentReason »Estimated payment datapaymentDate : date 0..1Payable less any payment adjustmentpaymentAmount : Money 0..1Payment identiferpaymentRef : Identifier 0..1Status of funds reservation (For provider, for Patient, None)reserved : Coding 0..1 « (For whom funds are to be reserved: (Patient, Provider, None)FundsReserve) »The form to be used for printing the contentform : Coding 0..1 « The forms codesForms »ItemsA service line numbersequenceLinkId : integer 1..1A list of note references to the notes provided belownoteNumber : integer 0..*ItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1ItemDetailA service line numbersequenceLinkId : integer 1..1DetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1SubDetailA service line numbersequenceLinkId : integer 1..1SubdetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1AddedItemList of input service items which this service line is intended to replacesequenceLinkId : integer 0..*A code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesServiceProduct) »The fee charged for the professional service or product.fee : Money 0..1A list of note references to the notes provided belownoteNumberLinkId : integer 0..*AddedItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesServiceProduct) »The fee charged for the professional service or product.fee : Money 0..1AddedItemDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1ErrorsThe sequence number of the line item submitted which contains the error. This value is ommitted when the error is elsewheresequenceLinkId : integer 0..1The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an AdditiondetailSequenceLinkId : integer 0..1The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an AdditionsubdetailSequenceLinkId : integer 0..1An error code,froma specified code system, which details why the claim could not be adjudicatedcode : Coding 1..1 « The error codes for adjudication processingAdjudicationError »NotesAn integer associated with each note which may be referred to from each service line itemnumber : integer 0..1The note purpose: Print/Displaytype : Coding 0..1 « The presentation types of notesNoteType »The note texttext : string 0..1CoverageA service line itemsequence : integer 1..1The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberRelationship) »A list of references from the Insurer to which these services pertainpreAuthRef : string 0..*The Coverages adjudication detailsclaimResponse : Reference(ClaimResponse) 0..1The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The third tier service adjudications for submitted servicessubDetail0..*The second tier service adjudications for submitted servicesdetail0..*The first tier service adjudications for submitted servicesitem0..*The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The second tier service adjudications for payor added servicesdetail0..*The first tier service adjudications for payor added servicesaddItem0..*Mutually exclusive with Services Provided (Item)error0..*Note textnote0..*Financial instrument by which payment information for health carecoverage0..*

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
  <noteNumber value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Money Monitary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[integer]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[integer]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[integer]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[integer]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Money Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[integer]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 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 -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : <integer>, // R!  Service instance
    "noteNumber" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : <integer>, // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : <integer>, // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Money }, // Monitary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : [<integer>], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumberLinkId" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Money }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : <integer>, // Item sequence number
    "detailSequenceLinkId" : <integer>, // Detail sequence number
    "subdetailSequenceLinkId" : <integer>, // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Money }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Money }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : <integer>, // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse DomainResourceRemittance resource
... identifier 0..*IdentifierResponse number
... request 0..1ClaimId of resource triggering adjudication
... ruleset 0..1CodingResource version
Ruleset (Example)
... originalRuleset 0..1CodingOriginal version
Ruleset (Example)
... created 0..1dateTimeCreation date
... organization 0..1OrganizationInsurer
... requestProvider 0..1PractitionerResponsible practitioner
... requestOrganization 0..1OrganizationResponsible organization
... outcome 0..1codecomplete | error
RemittanceOutcome (Required)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodingParty to be paid any benefits payable
PayeeType (Example)
... item 0..*ElementLine items
.... sequenceLinkId 1..1integerService instance
.... noteNumber 0..*integerList of note numbers which apply
.... adjudication 0..*ElementAdjudication details
..... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
..... amount 0..1MoneyMonitary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*ElementDetail line items
..... sequenceLinkId 1..1integerService instance
..... adjudication 0..*ElementDetail adjudication
...... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
...... amount 0..1MoneyMonitary amount
...... value 0..1decimalNon-monitory value
..... subDetail 0..*ElementSubdetail line items
...... sequenceLinkId 1..1integerService instance
...... adjudication 0..*ElementSubdetail adjudication
....... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
....... amount 0..1MoneyMonitary amount
....... value 0..1decimalNon-monitory value
... addItem 0..*ElementInsurer added line items
.... sequenceLinkId 0..*integerService instances
.... service 1..1CodingGroup, Service or Product
ServiceProduct (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumberLinkId 0..*integerList of note numbers which apply
.... adjudication 0..*ElementAdded items adjudication
..... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
..... amount 0..1MoneyMonitary amount
..... value 0..1decimalNon-monitory value
.... detail 0..*ElementAdded items details
..... service 1..1CodingService or Product
ServiceProduct (Example)
..... fee 0..1MoneyProfessional fee or Product charge
..... adjudication 0..*ElementAdded items detail adjudication
...... code 1..1CodingAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication (Required)
...... amount 0..1MoneyMonitary amount
...... value 0..1decimalNon-monitory value
... error 0..*ElementProcessing errors
.... sequenceLinkId 0..1integerItem sequence number
.... detailSequenceLinkId 0..1integerDetail sequence number
.... subdetailSequenceLinkId 0..1integerSubdetail sequence number
.... code 1..1CodingError code detailing processing issues
AdjudicationError (Required)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductable
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... paymentAdjustment 0..1MoneyPayment adjustment for non-Claim issues
... paymentAdjustmentReason 0..1CodingReason for Payment adjustment
AdjustmentReason (Required)
... paymentDate 0..1dateExpected data of Payment
... paymentAmount 0..1MoneyPayment amount
... paymentRef 0..1IdentifierPayment identifier
... reserved 0..1CodingFunds reserved status
FundsReserve (Example)
... form 0..1CodingPrinted Form Identifier
Forms (Required)
... note 0..*ElementProcessing notes
.... number 0..1integerNote Number for this note
.... type 0..1Codingdisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanitory text
... coverage 0..*ElementInsurance or medical plan
.... sequence 1..1integerService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1CoverageInsurance information
.... businessArrangement 0..1stringBusiness agreement
.... relationship 1..1CodingPatient relationship to subscriber
Relationship (Example)
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1ClaimResponseAdjudication results
.... originalRuleset 0..1CodingOriginal version
Ruleset (Example)

UML Diagram

ClaimResponse (DomainResource)The Response Business Identifieridentifier : Identifier 0..*Original request resource referrencerequest : Reference(Claim) 0..1The version of the style of resource contents. This should be mapped to the allowable profiles for this and supporting resourcesruleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The date when the enclosed suite of services were performed or completedcreated : dateTime 0..1The Insurer who produced this adjudicated responseorganization : Reference(Organization) 0..1The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference(Practitioner) 0..1The organization which is responsible for the services rendered to the patientrequestOrganization : Reference(Organization) 0..1Transaction status: error, completeoutcome : code 0..1 « The outcome of the processing.RemittanceOutcome »A description of the status of the adjudicationdisposition : string 0..1Party to be reimbursed: Subscriber, provider, otherpayeeType : Coding 0..1 « (A code for the party to be reimbursed.PayeeType) »The total cost of the services reportedtotalCost : Money 0..1The amount of deductable applied which was not allocated to any particular service lineunallocDeductable : Money 0..1Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductable)totalBenefit : Money 0..1Adjustment to the payment of this transaction which is not related to adjudication of this transactionpaymentAdjustment : Money 0..1Reason for the payment adjustmentpaymentAdjustmentReason : Coding 0..1 « Adjustment reason codesAdjustmentReason »Estimated payment datapaymentDate : date 0..1Payable less any payment adjustmentpaymentAmount : Money 0..1Payment identiferpaymentRef : Identifier 0..1Status of funds reservation (For provider, for Patient, None)reserved : Coding 0..1 « (For whom funds are to be reserved: (Patient, Provider, None)FundsReserve) »The form to be used for printing the contentform : Coding 0..1 « The forms codesForms »ItemsA service line numbersequenceLinkId : integer 1..1A list of note references to the notes provided belownoteNumber : integer 0..*ItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1ItemDetailA service line numbersequenceLinkId : integer 1..1DetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1SubDetailA service line numbersequenceLinkId : integer 1..1SubdetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1AddedItemList of input service items which this service line is intended to replacesequenceLinkId : integer 0..*A code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesServiceProduct) »The fee charged for the professional service or product.fee : Money 0..1A list of note references to the notes provided belownoteNumberLinkId : integer 0..*AddedItemAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1AddedItemsDetailA code to indicate the Professional Service or Product suppliedservice : Coding 1..1 « (Allowable service and product codesServiceProduct) »The fee charged for the professional service or product.fee : Money 0..1AddedItemDetailAdjudicationCode indicating: Co-Pay, deductable, elegible, benefit, tax, etccode : Coding 1..1 « The adjudication codesAdjudication »Monitory amount associated with the codeamount : Money 0..1A non-monitary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal 0..1ErrorsThe sequence number of the line item submitted which contains the error. This value is ommitted when the error is elsewheresequenceLinkId : integer 0..1The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an AdditiondetailSequenceLinkId : integer 0..1The sequence number of the addition within the line item submitted which contains the error. This value is ommitted when the error is not related to an AdditionsubdetailSequenceLinkId : integer 0..1An error code,froma specified code system, which details why the claim could not be adjudicatedcode : Coding 1..1 « The error codes for adjudication processingAdjudicationError »NotesAn integer associated with each note which may be referred to from each service line itemnumber : integer 0..1The note purpose: Print/Displaytype : Coding 0..1 « The presentation types of notesNoteType »The note texttext : string 0..1CoverageA service line itemsequence : integer 1..1The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean 1..1Reference to the program or plan identification, underwriter or payorcoverage : Reference(Coverage) 1..1The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string 0..1The relationship of the patient to the subscriberrelationship : Coding 1..1 « (The code for the relationship of the patient to the subscriberRelationship) »A list of references from the Insurer to which these services pertainpreAuthRef : string 0..*The Coverages adjudication detailsclaimResponse : Reference(ClaimResponse) 0..1The style (standard) and version of the original material which was converted into this resourceoriginalRuleset : Coding 0..1 « (The static and dynamic model to which contents conform, may be business version or standard and version.Ruleset) »The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The third tier service adjudications for submitted servicessubDetail0..*The second tier service adjudications for submitted servicesdetail0..*The first tier service adjudications for submitted servicesitem0..*The adjudications resultsadjudication0..*The adjudications resultsadjudication0..*The second tier service adjudications for payor added servicesdetail0..*The first tier service adjudications for payor added servicesaddItem0..*Mutually exclusive with Services Provided (Item)error0..*Note textnote0..*Financial instrument by which payment information for health carecoverage0..*

XML Template

<ClaimResponse xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <identifier><!-- 0..* Identifier Response  number --></identifier>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <ruleset><!-- 0..1 Coding Resource version --></ruleset>
 <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <organization><!-- 0..1 Reference(Organization) Insurer --></organization>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <outcome value="[code]"/><!-- 0..1 complete | error -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 Coding Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
  <noteNumber value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
   <adjudication>  <!-- 0..* Detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <sequenceLinkId value="[integer]"/><!-- 1..1 Service instance -->
    <adjudication>  <!-- 0..* Subdetail adjudication -->
     <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
     <amount><!-- 0..1 Money Monitary amount --></amount>
     <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
    </adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <sequenceLinkId value="[integer]"/><!-- 0..* Service instances -->
  <service><!-- 1..1 Coding Group, Service or Product --></service>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumberLinkId value="[integer]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Added items adjudication -->
   <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
   <amount><!-- 0..1 Money Monitary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
  </adjudication>
  <detail>  <!-- 0..* Added items details -->
   <service><!-- 1..1 Coding Service or Product --></service>
   <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
   <adjudication>  <!-- 0..* Added items detail adjudication -->
    <code><!-- 1..1 Coding Adjudication category such as co-pay, eligible, benefit, etc. --></code>
    <amount><!-- 0..1 Money Monitary amount --></amount>
    <value value="[decimal]"/><!-- 0..1 Non-monitory value -->
   </adjudication>
  </detail>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <sequenceLinkId value="[integer]"/><!-- 0..1 Item sequence number -->
  <detailSequenceLinkId value="[integer]"/><!-- 0..1 Detail sequence number -->
  <subdetailSequenceLinkId value="[integer]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 Coding Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductable --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <paymentAdjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></paymentAdjustment>
 <paymentAdjustmentReason><!-- 0..1 Coding Reason for Payment adjustment --></paymentAdjustmentReason>
 <paymentDate value="[date]"/><!-- 0..1 Expected data of Payment -->
 <paymentAmount><!-- 0..1 Money Payment amount --></paymentAmount>
 <paymentRef><!-- 0..1 Identifier Payment identifier --></paymentRef>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 Coding Printed Form Identifier --></form>
 <note>  <!-- 0..* Processing notes -->
  <number value="[integer]"/><!-- 0..1 Note Number for this note -->
  <type><!-- 0..1 Coding display | print | printoper --></type>
  <text value="[string]"/><!-- 0..1 Note explanitory text -->
 </note>
 <coverage>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[integer]"/><!-- 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 -->
  <relationship><!-- 1..1 Coding Patient relationship to subscriber --></relationship>
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
  <originalRuleset><!-- 0..1 Coding Original version --></originalRuleset>
 </coverage>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "ruleset" : { Coding }, // Resource version
  "originalRuleset" : { Coding }, // Original version
  "created" : "<dateTime>", // Creation date
  "organization" : { Reference(Organization) }, // Insurer
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "outcome" : "<code>", // complete | error
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { Coding }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "sequenceLinkId" : <integer>, // R!  Service instance
    "noteNumber" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Detail line items
      "sequenceLinkId" : <integer>, // R!  Service instance
      "adjudication" : [{ // Detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }],
      "subDetail" : [{ // Subdetail line items
        "sequenceLinkId" : <integer>, // R!  Service instance
        "adjudication" : [{ // Subdetail adjudication
          "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
          "amount" : { Money }, // Monitary amount
          "value" : <decimal> // Non-monitory value
        }]
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "sequenceLinkId" : [<integer>], // Service instances
    "service" : { Coding }, // R!  Group, Service or Product
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumberLinkId" : [<integer>], // List of note numbers which apply
    "adjudication" : [{ // Added items adjudication
      "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "amount" : { Money }, // Monitary amount
      "value" : <decimal> // Non-monitory value
    }],
    "detail" : [{ // Added items details
      "service" : { Coding }, // R!  Service or Product
      "fee" : { Money }, // Professional fee or Product charge
      "adjudication" : [{ // Added items detail adjudication
        "code" : { Coding }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
        "amount" : { Money }, // Monitary amount
        "value" : <decimal> // Non-monitory value
      }]
    }]
  }],
  "error" : [{ // Processing errors
    "sequenceLinkId" : <integer>, // Item sequence number
    "detailSequenceLinkId" : <integer>, // Detail sequence number
    "subdetailSequenceLinkId" : <integer>, // Subdetail sequence number
    "code" : { Coding } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductable
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "paymentAdjustment" : { Money }, // Payment adjustment for non-Claim issues
  "paymentAdjustmentReason" : { Coding }, // Reason for Payment adjustment
  "paymentDate" : "<date>", // Expected data of Payment
  "paymentAmount" : { Money }, // Payment amount
  "paymentRef" : { Identifier }, // Payment identifier
  "reserved" : { Coding }, // Funds reserved status
  "form" : { Coding }, // Printed Form Identifier
  "note" : [{ // Processing notes
    "number" : <integer>, // Note Number for this note
    "type" : { Coding }, // display | print | printoper
    "text" : "<string>" // Note explanitory text
  }],
  "coverage" : [{ // Insurance or medical plan
    "sequence" : <integer>, // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "relationship" : { Coding }, // R!  Patient relationship to subscriber
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) }, // Adjudication results
    "originalRuleset" : { Coding } // Original version
  }]
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

7.2.2.1 Terminology Bindings

PathDefinitionTypeReference
ClaimResponse.ruleset
ClaimResponse.originalRuleset
ClaimResponse.coverage.originalRuleset 		The static and dynamic model to which contents conform, may be business version or standard and version.Examplehttp://hl7.org/fhir/vs/ruleset
ClaimResponse.outcome The outcome of the processing.Requiredhttp://hl7.org/fhir/RS-link
ClaimResponse.payeeType A code for the party to be reimbursed.Examplehttp://hl7.org/fhir/vs/payeetype
ClaimResponse.item.adjudication.code
ClaimResponse.item.detail.adjudication.code
ClaimResponse.item.detail.subDetail.adjudication.code
ClaimResponse.addItem.adjudication.code
ClaimResponse.addItem.detail.adjudication.code 		The adjudication codesRequiredhttp://hl7.org/fhir/vs/adjudication
ClaimResponse.addItem.service
ClaimResponse.addItem.detail.service 		Allowable service and product codesExamplehttp://hl7.org/fhir/vs/service-uscls
ClaimResponse.error.code The error codes for adjudication processingRequiredhttp://hl7.org/fhir/vs/adjudication-error
ClaimResponse.paymentAdjustmentReason Adjustment reason codesRequiredhttp://hl7.org/fhir/vs/adjustment-reason
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None)Examplehttp://hl7.org/fhir/vs/fundsreserve
ClaimResponse.form The forms codesRequiredhttp://hl7.org/fhir/vs/forms
ClaimResponse.note.type The presentation types of notesRequiredhttp://hl7.org/fhir/NT-link
ClaimResponse.coverage.relationship The code for the relationship of the patient to the subscriberExamplehttp://hl7.org/fhir/vs/relationship

7.2.3 Search Parameters

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

NameTypeDescriptionPaths
identifiertokenThe identity of the insurerClaimResponse.identifier