This page is part of the FHIR Specification (v0.0.82: DSTU 1). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Claimresponse.questionnaire

This is an example form generated from the questionnaire. See also the XML or JSON format.

Claimresponse.questionnaire - FHIR v0.4.0 Form
Development Version

This is an example form generated from the questionnaire. See also the XML or JSON format

Remittance resource

ClaimResponse
ClaimResponse.id
ClaimResponse.id.value Logical id of this artefact
ClaimResponse.id 1

Metadata about the resource

ClaimResponse.meta
ClaimResponse.meta 1
ClaimResponse.implicitRules
ClaimResponse.implicitRules.value A set of rules under which this content was created
ClaimResponse.implicitRules 1
ClaimResponse.language
ClaimResponse.language.value language
ClaimResponse.language 1

Text summary of the resource, for human interpretation

ClaimResponse.text
ClaimResponse.text 1

Contained, inline Resources

ClaimResponse.contained
ClaimResponse.contained 1

Response number

ClaimResponse.identifier
ClaimResponse.identifier.label label:
ClaimResponse.identifier.system system:
ClaimResponse.identifier.value value:
ClaimResponse.identifier 1
ClaimResponse.request
ClaimResponse.request.value Id of resource triggering adjudication
ClaimResponse.request 1
ClaimResponse.ruleset
ClaimResponse.ruleset.value Resource version
ClaimResponse.ruleset 1
ClaimResponse.originalRuleset
ClaimResponse.originalRuleset.value Original version
ClaimResponse.originalRuleset 1
ClaimResponse.created
ClaimResponse.created.value Creation date
ClaimResponse.created 1
ClaimResponse.organization
ClaimResponse.organization.value Insurer
ClaimResponse.organization 1
ClaimResponse.requestProvider
ClaimResponse.requestProvider.value Responsible practitioner
ClaimResponse.requestProvider 1
ClaimResponse.requestOrganization
ClaimResponse.requestOrganization.value Responsible organization
ClaimResponse.requestOrganization 1
ClaimResponse.outcome
ClaimResponse.outcome.value outcome
ClaimResponse.outcome 1
ClaimResponse.disposition
ClaimResponse.disposition.value Disposition Message
ClaimResponse.disposition 1
ClaimResponse.payeeType
ClaimResponse.payeeType.value Party to be paid any benefits payable
ClaimResponse.payeeType 1

Line items

ClaimResponse.item
ClaimResponse.item.id
ClaimResponse.item.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.id 1
ClaimResponse.item.sequenceLinkId
ClaimResponse.item.sequenceLinkId.value Service instance
ClaimResponse.item.sequenceLinkId 1
ClaimResponse.item.noteNumber
ClaimResponse.item.noteNumber.value List of note numbers which apply
ClaimResponse.item.noteNumber 1

Adjudication details

ClaimResponse.item.adjudication
ClaimResponse.item.adjudication.id
ClaimResponse.item.adjudication.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.adjudication.id 1
ClaimResponse.item.adjudication.code
ClaimResponse.item.adjudication.code.value Adjudication category such as co-pay, eligible, benefit, etc.
ClaimResponse.item.adjudication.code 1

Monitary amount

ClaimResponse.item.adjudication.amount
ClaimResponse.item.adjudication.amount.value value:
ClaimResponse.item.adjudication.amount.currency currency:
ClaimResponse.item.adjudication.amount 1
ClaimResponse.item.adjudication.value
ClaimResponse.item.adjudication.value.value Non-monitory value
ClaimResponse.item.adjudication.value 1
ClaimResponse.item.adjudication 1

Detail line items

ClaimResponse.item.detail
ClaimResponse.item.detail.id
ClaimResponse.item.detail.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.detail.id 1
ClaimResponse.item.detail.sequenceLinkId
ClaimResponse.item.detail.sequenceLinkId.value Service instance
ClaimResponse.item.detail.sequenceLinkId 1

Detail adjudication

ClaimResponse.item.detail.adjudication
ClaimResponse.item.detail.adjudication.id
ClaimResponse.item.detail.adjudication.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.detail.adjudication.id 1
ClaimResponse.item.detail.adjudication.code
ClaimResponse.item.detail.adjudication.code.value Adjudication category such as co-pay, eligible, benefit, etc.
ClaimResponse.item.detail.adjudication.code 1

Monitary amount

ClaimResponse.item.detail.adjudication.amount
ClaimResponse.item.detail.adjudication.amount.value value:
ClaimResponse.item.detail.adjudication.amount.currency currency:
ClaimResponse.item.detail.adjudication.amount 1
ClaimResponse.item.detail.adjudication.value
ClaimResponse.item.detail.adjudication.value.value Non-monitory value
ClaimResponse.item.detail.adjudication.value 1
ClaimResponse.item.detail.adjudication 1

Subdetail line items

ClaimResponse.item.detail.subDetail
ClaimResponse.item.detail.subDetail.id
ClaimResponse.item.detail.subDetail.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.detail.subDetail.id 1
ClaimResponse.item.detail.subDetail.sequenceLinkId
ClaimResponse.item.detail.subDetail.sequenceLinkId.value Service instance
ClaimResponse.item.detail.subDetail.sequenceLinkId 1
Subdetail adjudication
ClaimResponse.item.detail.subDetail.adjudication
ClaimResponse.item.detail.subDetail.adjudication.id
ClaimResponse.item.detail.subDetail.adjudication.id.value xml:id (or equivalent in JSON)
ClaimResponse.item.detail.subDetail.adjudication.id 1
ClaimResponse.item.detail.subDetail.adjudication.code
ClaimResponse.item.detail.subDetail.adjudication.code.value Adjudication category such as co-pay, eligible, benefit, etc.
ClaimResponse.item.detail.subDetail.adjudication.code 1

Monitary amount

ClaimResponse.item.detail.subDetail.adjudication.amount
ClaimResponse.item.detail.subDetail.adjudication.amount.value value:
ClaimResponse.item.detail.subDetail.adjudication.amount.currency currency:
ClaimResponse.item.detail.subDetail.adjudication.amount 1
ClaimResponse.item.detail.subDetail.adjudication.value
ClaimResponse.item.detail.subDetail.adjudication.value.value Non-monitory value
ClaimResponse.item.detail.subDetail.adjudication.value 1
ClaimResponse.item.detail.subDetail.adjudication 1
ClaimResponse.item.detail.subDetail 1
ClaimResponse.item.detail 1
ClaimResponse.item 1

Insurer added line items

ClaimResponse.addItem
ClaimResponse.addItem.id
ClaimResponse.addItem.id.value xml:id (or equivalent in JSON)
ClaimResponse.addItem.id 1
ClaimResponse.addItem.sequenceLinkId
ClaimResponse.addItem.sequenceLinkId.value Service instances
ClaimResponse.addItem.sequenceLinkId 1
ClaimResponse.addItem.service
ClaimResponse.addItem.service.value Group, Service or Product
ClaimResponse.addItem.service 1

Professional fee or Product charge

ClaimResponse.addItem.fee
ClaimResponse.addItem.fee.value value:
ClaimResponse.addItem.fee.currency currency:
ClaimResponse.addItem.fee 1
ClaimResponse.addItem.noteNumberLinkId
ClaimResponse.addItem.noteNumberLinkId.value List of note numbers which apply
ClaimResponse.addItem.noteNumberLinkId 1

Added items adjudication

ClaimResponse.addItem.adjudication
ClaimResponse.addItem.adjudication.id
ClaimResponse.addItem.adjudication.id.value xml:id (or equivalent in JSON)
ClaimResponse.addItem.adjudication.id 1
ClaimResponse.addItem.adjudication.code
ClaimResponse.addItem.adjudication.code.value Adjudication category such as co-pay, eligible, benefit, etc.
ClaimResponse.addItem.adjudication.code 1

Monitary amount

ClaimResponse.addItem.adjudication.amount
ClaimResponse.addItem.adjudication.amount.value value:
ClaimResponse.addItem.adjudication.amount.currency currency:
ClaimResponse.addItem.adjudication.amount 1
ClaimResponse.addItem.adjudication.value
ClaimResponse.addItem.adjudication.value.value Non-monitory value
ClaimResponse.addItem.adjudication.value 1
ClaimResponse.addItem.adjudication 1

Added items details

ClaimResponse.addItem.detail
ClaimResponse.addItem.detail.id
ClaimResponse.addItem.detail.id.value xml:id (or equivalent in JSON)
ClaimResponse.addItem.detail.id 1
ClaimResponse.addItem.detail.service
ClaimResponse.addItem.detail.service.value Service or Product
ClaimResponse.addItem.detail.service 1

Professional fee or Product charge

ClaimResponse.addItem.detail.fee
ClaimResponse.addItem.detail.fee.value value:
ClaimResponse.addItem.detail.fee.currency currency:
ClaimResponse.addItem.detail.fee 1

Added items detail adjudication

ClaimResponse.addItem.detail.adjudication
ClaimResponse.addItem.detail.adjudication.id
ClaimResponse.addItem.detail.adjudication.id.value xml:id (or equivalent in JSON)
ClaimResponse.addItem.detail.adjudication.id 1
ClaimResponse.addItem.detail.adjudication.code
ClaimResponse.addItem.detail.adjudication.code.value Adjudication category such as co-pay, eligible, benefit, etc.
ClaimResponse.addItem.detail.adjudication.code 1

Monitary amount

ClaimResponse.addItem.detail.adjudication.amount
ClaimResponse.addItem.detail.adjudication.amount.value value:
ClaimResponse.addItem.detail.adjudication.amount.currency currency:
ClaimResponse.addItem.detail.adjudication.amount 1
ClaimResponse.addItem.detail.adjudication.value
ClaimResponse.addItem.detail.adjudication.value.value Non-monitory value
ClaimResponse.addItem.detail.adjudication.value 1
ClaimResponse.addItem.detail.adjudication 1
ClaimResponse.addItem.detail 1
ClaimResponse.addItem 1

Processing errors

ClaimResponse.error
ClaimResponse.error.id
ClaimResponse.error.id.value xml:id (or equivalent in JSON)
ClaimResponse.error.id 1
ClaimResponse.error.sequenceLinkId
ClaimResponse.error.sequenceLinkId.value Item sequence number
ClaimResponse.error.sequenceLinkId 1
ClaimResponse.error.detailSequenceLinkId
ClaimResponse.error.detailSequenceLinkId.value Detail sequence number
ClaimResponse.error.detailSequenceLinkId 1
ClaimResponse.error.subdetailSequenceLinkId
ClaimResponse.error.subdetailSequenceLinkId.value Subdetail sequence number
ClaimResponse.error.subdetailSequenceLinkId 1
ClaimResponse.error.code
ClaimResponse.error.code.value Error code detailing processing issues
ClaimResponse.error.code 1
ClaimResponse.error 1

Total Cost of service from the Claim

ClaimResponse.totalCost
ClaimResponse.totalCost.value value:
ClaimResponse.totalCost.currency currency:
ClaimResponse.totalCost 1

Unallocated deductable

ClaimResponse.unallocDeductable
ClaimResponse.unallocDeductable.value value:
ClaimResponse.unallocDeductable.currency currency:
ClaimResponse.unallocDeductable 1

Total benefit payable for the Claim

ClaimResponse.totalBenefit
ClaimResponse.totalBenefit.value value:
ClaimResponse.totalBenefit.currency currency:
ClaimResponse.totalBenefit 1

Payment adjustment for non-Claim issues

ClaimResponse.paymentAdjustment
ClaimResponse.paymentAdjustment.value value:
ClaimResponse.paymentAdjustment.currency currency:
ClaimResponse.paymentAdjustment 1
ClaimResponse.paymentAdjustmentReason
ClaimResponse.paymentAdjustmentReason.value Reason for Payment adjustment
ClaimResponse.paymentAdjustmentReason 1
ClaimResponse.paymentDate
ClaimResponse.paymentDate.value Expected data of Payment
ClaimResponse.paymentDate 1

Payment amount

ClaimResponse.paymentAmount
ClaimResponse.paymentAmount.value value:
ClaimResponse.paymentAmount.currency currency:
ClaimResponse.paymentAmount 1

Payment identifier

ClaimResponse.paymentRef
ClaimResponse.paymentRef.label label:
ClaimResponse.paymentRef.system system:
ClaimResponse.paymentRef.value value:
ClaimResponse.paymentRef 1
ClaimResponse.reserved
ClaimResponse.reserved.value Funds reserved status
ClaimResponse.reserved 1
ClaimResponse.form
ClaimResponse.form.value Printed Form Identifier
ClaimResponse.form 1

Processing notes

ClaimResponse.note
ClaimResponse.note.id
ClaimResponse.note.id.value xml:id (or equivalent in JSON)
ClaimResponse.note.id 1
ClaimResponse.note.number
ClaimResponse.note.number.value Note Number for this note
ClaimResponse.note.number 1
ClaimResponse.note.type
ClaimResponse.note.type.value display | print | printoper
ClaimResponse.note.type 1
ClaimResponse.note.text
ClaimResponse.note.text.value Note explanitory text
ClaimResponse.note.text 1
ClaimResponse.note 1

Insurance or medical plan

ClaimResponse.coverage
ClaimResponse.coverage.id
ClaimResponse.coverage.id.value xml:id (or equivalent in JSON)
ClaimResponse.coverage.id 1
ClaimResponse.coverage.sequence
ClaimResponse.coverage.sequence.value Service instance identifier
ClaimResponse.coverage.sequence 1
ClaimResponse.coverage.focal
ClaimResponse.coverage.focal.value Is the focal Coverage
ClaimResponse.coverage.focal 1
ClaimResponse.coverage.coverage
ClaimResponse.coverage.coverage.value Insurance information
ClaimResponse.coverage.coverage 1
ClaimResponse.coverage.businessArrangement
ClaimResponse.coverage.businessArrangement.value Business agreement
ClaimResponse.coverage.businessArrangement 1
ClaimResponse.coverage.relationship
ClaimResponse.coverage.relationship.value Patient relationship to subscriber
ClaimResponse.coverage.relationship 1
ClaimResponse.coverage.preAuthRef
ClaimResponse.coverage.preAuthRef.value Pre-Authorization/Determination Reference
ClaimResponse.coverage.preAuthRef 1
ClaimResponse.coverage.claimResponse
ClaimResponse.coverage.claimResponse.value Adjudication results
ClaimResponse.coverage.claimResponse 1
ClaimResponse.coverage.originalRuleset
ClaimResponse.coverage.originalRuleset.value Original version
ClaimResponse.coverage.originalRuleset 1
ClaimResponse.coverage 1
ClaimResponse 1