R4 Draft for Comment

This page is part of the FHIR Specification (v3.2.0: R4 Ballot 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 . Page versions: R5 R4B R4 R3 R2

13.7 Resource ClaimResponse - Content

Financial Management Work GroupMaturity Level: 2 Trial Use Compartments: Patient, Practitioner

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

13.7.1 Scope and Usage

The ClaimResponse resource provides application level error or application level adjudication results which are the result of processing a submitted Claim resource where that Claim may be which is the functional corollary of a Claim, Pre-Determination or a Pre-Authorization.

This is the adjudicated response to a Claim, Pre-determination or Pre-Authorization. The strength of the payment aspect of the response is matching to the strength of the original request. For a Claim the adjudication indicates payment which is intended to be made, for Pre-Authorization and Pre-Determination no payment will actually be made however funds may be reserved to settle a claim submitted later. Only an actual claim may be expected to result in actual payment.

The ClaimResponse resource is the response for the submission of: Claim, Re-adjudication and Reversals.

The ClaimResponse may have been created by interpreting the corresponding Claim resource as a request for payment (the oldest sense of a claim), a request for preauthorization or a request for predetermination. These interpretations are described at the Claim resource. It is possible for the consumer of the ClaimResponse resource to know the manner in which the Claim resource was processed by checking the Claim.use code.

Where the producer of the ClaimResponse resource interpreted the Claim as a traditional claim, the contents of the ClaimResponse includes information that the producer of the ClaimResponse intends to pay. The actual payment, however, is conveyed separately, perhaps through an eletronic funds transfer protocol outside the domain of FHIR or possibly by a paper check.

However, when the producer of the ClaimResponse interpreted the Claim as request for preauthorization or predetermination, the ClaimResponse does not imply that such a payment is pending. Actual payment would only follow the interpretation fo a Claim resource as a traditional claim.

This resource is referenced by Claim, DeviceRequest, ExplanationOfBenefit, MedicationRequest and ServiceRequest

13.7.2 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse TUDomainResourceRemittance resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierResponse number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... created 0..1dateTimeCreation date
... insurer 0..1Reference(Organization)Insurance issuing organization
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(Claim)Id of resource triggering adjudication
... outcome 0..1codecomplete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Claim Payee Type Codes (Example)
... item 0..*BackboneElementLine items
.... itemSequence 1..1positiveIntService instance
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementDetail line items
..... detailSequence 1..1positiveIntService instance
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementSubdetail line items
...... subDetailSequence 1..1positiveIntService instance
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntService instances
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... service 0..1CodeableConceptGroup, Service or Product
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
... error 0..*BackboneElementProcessing errors
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Example)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductible
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment details, if paid
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected data of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... reserved 0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... processNote 0..*BackboneElementProcessing notes
.... number 0..1positiveIntSequence Number for this note
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage if different from the resource
Common Languages (Extensible but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format

UML Diagram (Legend)

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Patient Resourcepatient : Reference [0..1] « Patient »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseinsurer : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Original request resource referrencerequest : Reference [0..1] « Claim »Transaction: error, complete, partial processingoutcome : code [0..1] « The result of the claim processing (Strength=Required)Claim Processing ! »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »The total cost of the services reportedtotalCost : Money [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : Money [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)totalBenefit : Money [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »Request for additional supporting or authorizing information, such as: documents, images or resourcescommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA service line numberitemSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)Adjudication Value ?? »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example)Adjudication Reason ?? »Monetary amount associated with the codeamount : Money [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA service line numberdetailSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersubDetailSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemList of input service items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubdetailSequence : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhereitemSequence : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequence : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubDetailSequence : positiveInt [0..1]An error code,from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « The adjudication error codes. (Strength=Example)Adjudication Error ?? »PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example)Payment Adjustment Reason ?? »Estimated payment datadate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identifieridentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Extensible)Common Languages+ »InsuranceA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The adjudication resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The third tier service adjudications for submitted servicessubDetail[0..*]The second tier service adjudications for submitted servicesdetail[0..*]The first tier service adjudications for submitted servicesitem[0..*]The adjudications resultsadjudication[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]Mutually exclusive with Services Provided (Item)error[0..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textprocessNote[0..*]Financial instrument by which payment information for health careinsurance[0..*]

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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurance issuing organization
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "itemSequence" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "detailSequence" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Subdetail line items
        "subDetailSequence" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items adjudication
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2

ClaimResponse
ClaimResponse.status
  • Added Element
ClaimResponse.patient
  • Added Element
ClaimResponse.insurer
  • Added Element
ClaimResponse.payeeType
  • Type changed from Coding to CodeableConcept
ClaimResponse.item.itemSequence
  • Added Element
ClaimResponse.item.adjudication.category
  • Added Element
ClaimResponse.item.adjudication.reason
  • Added Element
ClaimResponse.item.adjudication.amount
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.detailSequence
  • Added Element
ClaimResponse.item.detail.noteNumber
  • Added Element
ClaimResponse.item.detail.adjudication
  • Remove BackboneElement
ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Element
ClaimResponse.item.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.item.detail.subDetail.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier
  • Added Element
ClaimResponse.addItem.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber
  • Added Element
ClaimResponse.addItem.adjudication
  • Remove BackboneElement
ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.error.code
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse.totalCost
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment
  • Added Element
ClaimResponse.payment.type
  • Added Element
ClaimResponse.payment.adjustment
  • Added Element
ClaimResponse.payment.adjustmentReason
  • Added Element
ClaimResponse.payment.date
  • Added Element
ClaimResponse.payment.amount
  • Added Element
ClaimResponse.payment.identifier
  • Added Element
ClaimResponse.form
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/forms (required)
ClaimResponse.processNote
  • Added Element
ClaimResponse.processNote.number
  • Added Element
ClaimResponse.processNote.type
  • Added Element
ClaimResponse.processNote.text
  • Added Element
ClaimResponse.processNote.language
  • Added Element
ClaimResponse.communicationRequest
  • Added Element
ClaimResponse.insurance
  • Added Element
ClaimResponse.insurance.sequence
  • Added Element
ClaimResponse.insurance.focal
  • Added Element
ClaimResponse.insurance.coverage
  • Added Element
ClaimResponse.insurance.businessArrangement
  • Added Element
ClaimResponse.insurance.preAuthRef
  • Added Element
ClaimResponse.insurance.claimResponse
  • Added Element
ClaimResponse.ruleset
  • deleted
ClaimResponse.originalRuleset
  • deleted
ClaimResponse.organization
  • deleted
ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.adjudication.code
  • deleted
ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.amount
  • deleted
ClaimResponse.item.detail.adjudication.value
  • deleted
ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value
  • deleted
ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.addItem.noteNumberLinkId
  • deleted
ClaimResponse.addItem.adjudication.code
  • deleted
ClaimResponse.addItem.adjudication.amount
  • deleted
ClaimResponse.addItem.adjudication.value
  • deleted
ClaimResponse.addItem.detail
  • deleted
ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.paymentAdjustment
  • deleted
ClaimResponse.paymentAdjustmentReason
  • deleted
ClaimResponse.paymentDate
  • deleted
ClaimResponse.paymentAmount
  • deleted
ClaimResponse.paymentRef
  • deleted
ClaimResponse.note
  • deleted
ClaimResponse.coverage
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClaimResponse TUDomainResourceRemittance resource
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... identifier 0..*IdentifierResponse number
... status ?!Σ0..1codeactive | cancelled | draft | entered-in-error
Financial Resource Status Codes (Required)
... patient 0..1Reference(Patient)The subject of the Products and Services
... created 0..1dateTimeCreation date
... insurer 0..1Reference(Organization)Insurance issuing organization
... requestProvider 0..1Reference(Practitioner)Responsible practitioner
... requestOrganization 0..1Reference(Organization)Responsible organization
... request 0..1Reference(Claim)Id of resource triggering adjudication
... outcome 0..1codecomplete | error | partial
Claim Processing Codes (Required)
... disposition 0..1stringDisposition Message
... payeeType 0..1CodeableConceptParty to be paid any benefits payable
Claim Payee Type Codes (Example)
... item 0..*BackboneElementLine items
.... itemSequence 1..1positiveIntService instance
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*BackboneElementAdjudication details
..... category 1..1CodeableConceptAdjudication category such as co-pay, eligible, benefit, etc.
Adjudication Value Codes (Example)
..... reason 0..1CodeableConceptExplanation of Adjudication outcome
Adjudication Reason Codes (Example)
..... amount 0..1MoneyMonetary amount
..... value 0..1decimalNon-monetary value
.... detail 0..*BackboneElementDetail line items
..... detailSequence 1..1positiveIntService instance
..... noteNumber 0..*positiveIntList of note numbers which apply
..... adjudication 0..*see adjudicationDetail level adjudication details
..... subDetail 0..*BackboneElementSubdetail line items
...... subDetailSequence 1..1positiveIntService instance
...... noteNumber 0..*positiveIntList of note numbers which apply
...... adjudication 0..*see adjudicationSubdetail level adjudication details
... addItem 0..*BackboneElementInsurer added line items
.... itemSequence 0..*positiveIntService instances
.... detailSequence 0..*positiveIntDetail sequence number
.... subdetailSequence 0..*positiveIntSubdetail sequence number
.... service 0..1CodeableConceptGroup, Service or Product
USCLS Codes (Example)
.... modifier 0..*CodeableConceptService/Product billing modifiers
Modifier type Codes (Example)
.... fee 0..1MoneyProfessional fee or Product charge
.... noteNumber 0..*positiveIntList of note numbers which apply
.... adjudication 0..*see adjudicationAdded items adjudication
... error 0..*BackboneElementProcessing errors
.... itemSequence 0..1positiveIntItem sequence number
.... detailSequence 0..1positiveIntDetail sequence number
.... subDetailSequence 0..1positiveIntSubdetail sequence number
.... code 1..1CodeableConceptError code detailing processing issues
Adjudication Error Codes (Example)
... totalCost 0..1MoneyTotal Cost of service from the Claim
... unallocDeductable 0..1MoneyUnallocated deductible
... totalBenefit 0..1MoneyTotal benefit payable for the Claim
... payment 0..1BackboneElementPayment details, if paid
.... type 0..1CodeableConceptPartial or Complete
Example Payment Type Codes (Example)
.... adjustment 0..1MoneyPayment adjustment for non-Claim issues
.... adjustmentReason 0..1CodeableConceptExplanation for the non-claim adjustment
Payment Adjustment Reason Codes (Example)
.... date 0..1dateExpected data of Payment
.... amount 0..1MoneyPayable amount after adjustment
.... identifier 0..1IdentifierIdentifier of the payment instrument
... reserved 0..1CodingFunds reserved status
Funds Reservation Codes (Example)
... form 0..1CodeableConceptPrinted Form Identifier
Form Codes (Example)
... processNote 0..*BackboneElementProcessing notes
.... number 0..1positiveIntSequence Number for this note
.... type 0..1codedisplay | print | printoper
NoteType (Required)
.... text 0..1stringNote explanatory text
.... language 0..1CodeableConceptLanguage if different from the resource
Common Languages (Extensible but limited to All Languages)
... communicationRequest 0..*Reference(CommunicationRequest)Request for additional information
... insurance 0..*BackboneElementInsurance or medical plan
.... sequence 1..1positiveIntService instance identifier
.... focal 1..1booleanIs the focal Coverage
.... coverage 1..1Reference(Coverage)Insurance information
.... businessArrangement 0..1stringBusiness agreement
.... preAuthRef 0..*stringPre-Authorization/Determination Reference
.... claimResponse 0..1Reference(ClaimResponse)Adjudication results

doco Documentation for this format

UML Diagram (Legend)

ClaimResponse (DomainResource)The Response business identifieridentifier : Identifier [0..*]The status of the resource instance (this element modifies the meaning of other elements)status : code [0..1] « A code specifying the state of the resource instance. (Strength=Required)Financial Resource Status ! »Patient Resourcepatient : Reference [0..1] « Patient »The date when the enclosed suite of services were performed or completedcreated : dateTime [0..1]The Insurer who produced this adjudicated responseinsurer : Reference [0..1] « Organization »The practitioner who is responsible for the services rendered to the patientrequestProvider : Reference [0..1] « Practitioner »The organization which is responsible for the services rendered to the patientrequestOrganization : Reference [0..1] « Organization »Original request resource referrencerequest : Reference [0..1] « Claim »Transaction: error, complete, partial processingoutcome : code [0..1] « The result of the claim processing (Strength=Required)Claim Processing ! »A description of the status of the adjudicationdisposition : string [0..1]Party to be reimbursed: Subscriber, provider, otherpayeeType : CodeableConcept [0..1] « A code for the party to be reimbursed. (Strength=Example)Claim Payee Type ?? »The total cost of the services reportedtotalCost : Money [0..1]The amount of deductible applied which was not allocated to any particular service lineunallocDeductable : Money [0..1]Total amount of benefit payable (Equal to sum of the Benefit amounts from all detail lines and additions less the Unallocated Deductible)totalBenefit : Money [0..1]Status of funds reservation (For provider, for Patient, None)reserved : Coding [0..1] « For whom funds are to be reserved: (Patient, Provider, None). (Strength=Example)Funds Reservation ?? »The form to be used for printing the contentform : CodeableConcept [0..1] « The forms codes. (Strength=Example)Form ?? »Request for additional supporting or authorizing information, such as: documents, images or resourcescommunicationRequest : Reference [0..*] « CommunicationRequest »ItemA service line numberitemSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AdjudicationCode indicating: Co-Pay, deductible, eligible, benefit, tax, etccategory : CodeableConcept [1..1] « The adjudication codes. (Strength=Example)Adjudication Value ?? »Adjudication reason such as limit reachedreason : CodeableConcept [0..1] « The adjudication reason codes. (Strength=Example)Adjudication Reason ?? »Monetary amount associated with the codeamount : Money [0..1]A non-monetary value for example a percentage. Mutually exclusive to the amount element abovevalue : decimal [0..1]ItemDetailA service line numberdetailSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]SubDetailA service line numbersubDetailSequence : positiveInt [1..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]AddedItemList of input service items which this service line is intended to replaceitemSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequence : positiveInt [0..*]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubdetailSequence : positiveInt [0..*]A code to indicate the Professional Service or Product suppliedservice : CodeableConcept [0..1] « Allowable service and product codes. (Strength=Example)USCLS ?? »Item typification or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or for medical whether the treatment was outside the clinic or out of office hoursmodifier : CodeableConcept [0..*] « Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen. (Strength=Example)Modifier type ?? »The fee charged for the professional service or product.fee : Money [0..1]A list of note references to the notes provided belownoteNumber : positiveInt [0..*]ErrorThe sequence number of the line item submitted which contains the error. This value is omitted when the error is elsewhereitemSequence : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditiondetailSequence : positiveInt [0..1]The sequence number of the addition within the line item submitted which contains the error. This value is omitted when the error is not related to an AdditionsubDetailSequence : positiveInt [0..1]An error code,from a specified code system, which details why the claim could not be adjudicatedcode : CodeableConcept [1..1] « The adjudication error codes. (Strength=Example)Adjudication Error ?? »PaymentWhether this represents partial or complete payment of the claimtype : CodeableConcept [0..1] « The type (partial, complete) of the payment (Strength=Example)Example Payment Type ?? »Adjustment to the payment of this transaction which is not related to adjudication of this transactionadjustment : Money [0..1]Reason for the payment adjustmentadjustmentReason : CodeableConcept [0..1] « Payment Adjustment reason codes. (Strength=Example)Payment Adjustment Reason ?? »Estimated payment datadate : date [0..1]Payable less any payment adjustmentamount : Money [0..1]Payment identifieridentifier : Identifier [0..1]NoteAn integer associated with each note which may be referred to from each service line itemnumber : positiveInt [0..1]The note purpose: Print/Displaytype : code [0..1] « The presentation types of notes. (Strength=Required)NoteType! »The note texttext : string [0..1]The ISO-639-1 alpha 2 code in lower case for the language, optionally followed by a hyphen and the ISO-3166-1 alpha 2 code for the region in upper case; e.g. "en" for English, or "en-US" for American English versus "en-EN" for England Englishlanguage : CodeableConcept [0..1] « A human language. (Strength=Extensible)Common Languages+ »InsuranceA service line itemsequence : positiveInt [1..1]The instance number of the Coverage which is the focus for adjudication. The Coverage against which the claim is to be adjudicatedfocal : boolean [1..1]Reference to the program or plan identification, underwriter or payorcoverage : Reference [1..1] « Coverage »The contract number of a business agreement which describes the terms and conditionsbusinessArrangement : string [0..1]A list of references from the Insurer to which these services pertainpreAuthRef : string [0..*]The Coverages adjudication detailsclaimResponse : Reference [0..1] « ClaimResponse »The adjudication resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The adjudications resultsadjudication[0..*]The third tier service adjudications for submitted servicessubDetail[0..*]The second tier service adjudications for submitted servicesdetail[0..*]The first tier service adjudications for submitted servicesitem[0..*]The adjudications resultsadjudication[0..*]The first tier service adjudications for payor added servicesaddItem[0..*]Mutually exclusive with Services Provided (Item)error[0..*]Payment details for the claim if the claim has been paidpayment[0..1]Note textprocessNote[0..*]Financial instrument by which payment information for health careinsurance[0..*]

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>
 <status value="[code]"/><!-- 0..1 active | cancelled | draft | entered-in-error -->
 <patient><!-- 0..1 Reference(Patient) The subject of the Products and Services --></patient>
 <created value="[dateTime]"/><!-- 0..1 Creation date -->
 <insurer><!-- 0..1 Reference(Organization) Insurance issuing organization --></insurer>
 <requestProvider><!-- 0..1 Reference(Practitioner) Responsible practitioner --></requestProvider>
 <requestOrganization><!-- 0..1 Reference(Organization) Responsible organization --></requestOrganization>
 <request><!-- 0..1 Reference(Claim) Id of resource triggering adjudication --></request>
 <outcome value="[code]"/><!-- 0..1 complete | error | partial -->
 <disposition value="[string]"/><!-- 0..1 Disposition Message -->
 <payeeType><!-- 0..1 CodeableConcept Party to be paid any benefits payable --></payeeType>
 <item>  <!-- 0..* Line items -->
  <itemSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication>  <!-- 0..* Adjudication details -->
   <category><!-- 1..1 CodeableConcept Adjudication category such as co-pay, eligible, benefit, etc. --></category>
   <reason><!-- 0..1 CodeableConcept Explanation of Adjudication outcome --></reason>
   <amount><!-- 0..1 Money Monetary amount --></amount>
   <value value="[decimal]"/><!-- 0..1 Non-monetary value -->
  </adjudication>
  <detail>  <!-- 0..* Detail line items -->
   <detailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
   <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
   <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Detail level adjudication details --></adjudication>
   <subDetail>  <!-- 0..* Subdetail line items -->
    <subDetailSequence value="[positiveInt]"/><!-- 1..1 Service instance -->
    <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
    <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Subdetail level adjudication details --></adjudication>
   </subDetail>
  </detail>
 </item>
 <addItem>  <!-- 0..* Insurer added line items -->
  <itemSequence value="[positiveInt]"/><!-- 0..* Service instances -->
  <detailSequence value="[positiveInt]"/><!-- 0..* Detail sequence number -->
  <subdetailSequence value="[positiveInt]"/><!-- 0..* Subdetail sequence number -->
  <service><!-- 0..1 CodeableConcept Group, Service or Product --></service>
  <modifier><!-- 0..* CodeableConcept Service/Product billing modifiers --></modifier>
  <fee><!-- 0..1 Money Professional fee or Product charge --></fee>
  <noteNumber value="[positiveInt]"/><!-- 0..* List of note numbers which apply -->
  <adjudication><!-- 0..* Content as for ClaimResponse.item.adjudication Added items adjudication --></adjudication>
 </addItem>
 <error>  <!-- 0..* Processing errors -->
  <itemSequence value="[positiveInt]"/><!-- 0..1 Item sequence number -->
  <detailSequence value="[positiveInt]"/><!-- 0..1 Detail sequence number -->
  <subDetailSequence value="[positiveInt]"/><!-- 0..1 Subdetail sequence number -->
  <code><!-- 1..1 CodeableConcept Error code detailing processing issues --></code>
 </error>
 <totalCost><!-- 0..1 Money Total Cost of service from the Claim --></totalCost>
 <unallocDeductable><!-- 0..1 Money Unallocated deductible --></unallocDeductable>
 <totalBenefit><!-- 0..1 Money Total benefit payable for the Claim --></totalBenefit>
 <payment>  <!-- 0..1 Payment details, if paid -->
  <type><!-- 0..1 CodeableConcept Partial or Complete --></type>
  <adjustment><!-- 0..1 Money Payment adjustment for non-Claim issues --></adjustment>
  <adjustmentReason><!-- 0..1 CodeableConcept Explanation for the non-claim adjustment --></adjustmentReason>
  <date value="[date]"/><!-- 0..1 Expected data of Payment -->
  <amount><!-- 0..1 Money Payable amount after adjustment --></amount>
  <identifier><!-- 0..1 Identifier Identifier of the payment instrument --></identifier>
 </payment>
 <reserved><!-- 0..1 Coding Funds reserved status --></reserved>
 <form><!-- 0..1 CodeableConcept Printed Form Identifier --></form>
 <processNote>  <!-- 0..* Processing notes -->
  <number value="[positiveInt]"/><!-- 0..1 Sequence Number for this note -->
  <type value="[code]"/><!-- 0..1 display | print | printoper -->
  <text value="[string]"/><!-- 0..1 Note explanatory text -->
  <language><!-- 0..1 CodeableConcept Language if different from the resource --></language>
 </processNote>
 <communicationRequest><!-- 0..* Reference(CommunicationRequest) Request for additional information --></communicationRequest>
 <insurance>  <!-- 0..* Insurance or medical plan -->
  <sequence value="[positiveInt]"/><!-- 1..1 Service instance identifier -->
  <focal value="[boolean]"/><!-- 1..1 Is the focal Coverage -->
  <coverage><!-- 1..1 Reference(Coverage) Insurance information --></coverage>
  <businessArrangement value="[string]"/><!-- 0..1 Business agreement -->
  <preAuthRef value="[string]"/><!-- 0..* Pre-Authorization/Determination Reference -->
  <claimResponse><!-- 0..1 Reference(ClaimResponse) Adjudication results --></claimResponse>
 </insurance>
</ClaimResponse>

JSON Template

{doco
  "resourceType" : "ClaimResponse",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "identifier" : [{ Identifier }], // Response  number
  "status" : "<code>", // active | cancelled | draft | entered-in-error
  "patient" : { Reference(Patient) }, // The subject of the Products and Services
  "created" : "<dateTime>", // Creation date
  "insurer" : { Reference(Organization) }, // Insurance issuing organization
  "requestProvider" : { Reference(Practitioner) }, // Responsible practitioner
  "requestOrganization" : { Reference(Organization) }, // Responsible organization
  "request" : { Reference(Claim) }, // Id of resource triggering adjudication
  "outcome" : "<code>", // complete | error | partial
  "disposition" : "<string>", // Disposition Message
  "payeeType" : { CodeableConcept }, // Party to be paid any benefits payable
  "item" : [{ // Line items
    "itemSequence" : "<positiveInt>", // R!  Service instance
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ // Adjudication details
      "category" : { CodeableConcept }, // R!  Adjudication category such as co-pay, eligible, benefit, etc.
      "reason" : { CodeableConcept }, // Explanation of Adjudication outcome
      "amount" : { Money }, // Monetary amount
      "value" : <decimal> // Non-monetary value
    }],
    "detail" : [{ // Detail line items
      "detailSequence" : "<positiveInt>", // R!  Service instance
      "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
      "adjudication" : [{ Content as for ClaimResponse.item.adjudication }], // Detail level adjudication details
      "subDetail" : [{ // Subdetail line items
        "subDetailSequence" : "<positiveInt>", // R!  Service instance
        "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
        "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Subdetail level adjudication details
      }]
    }]
  }],
  "addItem" : [{ // Insurer added line items
    "itemSequence" : ["<positiveInt>"], // Service instances
    "detailSequence" : ["<positiveInt>"], // Detail sequence number
    "subdetailSequence" : ["<positiveInt>"], // Subdetail sequence number
    "service" : { CodeableConcept }, // Group, Service or Product
    "modifier" : [{ CodeableConcept }], // Service/Product billing modifiers
    "fee" : { Money }, // Professional fee or Product charge
    "noteNumber" : ["<positiveInt>"], // List of note numbers which apply
    "adjudication" : [{ Content as for ClaimResponse.item.adjudication }] // Added items adjudication
  }],
  "error" : [{ // Processing errors
    "itemSequence" : "<positiveInt>", // Item sequence number
    "detailSequence" : "<positiveInt>", // Detail sequence number
    "subDetailSequence" : "<positiveInt>", // Subdetail sequence number
    "code" : { CodeableConcept } // R!  Error code detailing processing issues
  }],
  "totalCost" : { Money }, // Total Cost of service from the Claim
  "unallocDeductable" : { Money }, // Unallocated deductible
  "totalBenefit" : { Money }, // Total benefit payable for the Claim
  "payment" : { // Payment details, if paid
    "type" : { CodeableConcept }, // Partial or Complete
    "adjustment" : { Money }, // Payment adjustment for non-Claim issues
    "adjustmentReason" : { CodeableConcept }, // Explanation for the non-claim adjustment
    "date" : "<date>", // Expected data of Payment
    "amount" : { Money }, // Payable amount after adjustment
    "identifier" : { Identifier } // Identifier of the payment instrument
  },
  "reserved" : { Coding }, // Funds reserved status
  "form" : { CodeableConcept }, // Printed Form Identifier
  "processNote" : [{ // Processing notes
    "number" : "<positiveInt>", // Sequence Number for this note
    "type" : "<code>", // display | print | printoper
    "text" : "<string>", // Note explanatory text
    "language" : { CodeableConcept } // Language if different from the resource
  }],
  "communicationRequest" : [{ Reference(CommunicationRequest) }], // Request for additional information
  "insurance" : [{ // Insurance or medical plan
    "sequence" : "<positiveInt>", // R!  Service instance identifier
    "focal" : <boolean>, // R!  Is the focal Coverage
    "coverage" : { Reference(Coverage) }, // R!  Insurance information
    "businessArrangement" : "<string>", // Business agreement
    "preAuthRef" : ["<string>"], // Pre-Authorization/Determination Reference
    "claimResponse" : { Reference(ClaimResponse) } // Adjudication results
  }]
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:ClaimResponse;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:ClaimResponse.identifier [ Identifier ], ... ; # 0..* Response  number
  fhir:ClaimResponse.status [ code ]; # 0..1 active | cancelled | draft | entered-in-error
  fhir:ClaimResponse.patient [ Reference(Patient) ]; # 0..1 The subject of the Products and Services
  fhir:ClaimResponse.created [ dateTime ]; # 0..1 Creation date
  fhir:ClaimResponse.insurer [ Reference(Organization) ]; # 0..1 Insurance issuing organization
  fhir:ClaimResponse.requestProvider [ Reference(Practitioner) ]; # 0..1 Responsible practitioner
  fhir:ClaimResponse.requestOrganization [ Reference(Organization) ]; # 0..1 Responsible organization
  fhir:ClaimResponse.request [ Reference(Claim) ]; # 0..1 Id of resource triggering adjudication
  fhir:ClaimResponse.outcome [ code ]; # 0..1 complete | error | partial
  fhir:ClaimResponse.disposition [ string ]; # 0..1 Disposition Message
  fhir:ClaimResponse.payeeType [ CodeableConcept ]; # 0..1 Party to be paid any benefits payable
  fhir:ClaimResponse.item [ # 0..* Line items
    fhir:ClaimResponse.item.itemSequence [ positiveInt ]; # 1..1 Service instance
    fhir:ClaimResponse.item.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.item.adjudication [ # 0..* Adjudication details
      fhir:ClaimResponse.item.adjudication.category [ CodeableConcept ]; # 1..1 Adjudication category such as co-pay, eligible, benefit, etc.
      fhir:ClaimResponse.item.adjudication.reason [ CodeableConcept ]; # 0..1 Explanation of Adjudication outcome
      fhir:ClaimResponse.item.adjudication.amount [ Money ]; # 0..1 Monetary amount
      fhir:ClaimResponse.item.adjudication.value [ decimal ]; # 0..1 Non-monetary value
    ], ...;
    fhir:ClaimResponse.item.detail [ # 0..* Detail line items
      fhir:ClaimResponse.item.detail.detailSequence [ positiveInt ]; # 1..1 Service instance
      fhir:ClaimResponse.item.detail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
      fhir:ClaimResponse.item.detail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Detail level adjudication details
      fhir:ClaimResponse.item.detail.subDetail [ # 0..* Subdetail line items
        fhir:ClaimResponse.item.detail.subDetail.subDetailSequence [ positiveInt ]; # 1..1 Service instance
        fhir:ClaimResponse.item.detail.subDetail.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
        fhir:ClaimResponse.item.detail.subDetail.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Subdetail level adjudication details
      ], ...;
    ], ...;
  ], ...;
  fhir:ClaimResponse.addItem [ # 0..* Insurer added line items
    fhir:ClaimResponse.addItem.itemSequence [ positiveInt ], ... ; # 0..* Service instances
    fhir:ClaimResponse.addItem.detailSequence [ positiveInt ], ... ; # 0..* Detail sequence number
    fhir:ClaimResponse.addItem.subdetailSequence [ positiveInt ], ... ; # 0..* Subdetail sequence number
    fhir:ClaimResponse.addItem.service [ CodeableConcept ]; # 0..1 Group, Service or Product
    fhir:ClaimResponse.addItem.modifier [ CodeableConcept ], ... ; # 0..* Service/Product billing modifiers
    fhir:ClaimResponse.addItem.fee [ Money ]; # 0..1 Professional fee or Product charge
    fhir:ClaimResponse.addItem.noteNumber [ positiveInt ], ... ; # 0..* List of note numbers which apply
    fhir:ClaimResponse.addItem.adjudication [ See ClaimResponse.item.adjudication ], ... ; # 0..* Added items adjudication
  ], ...;
  fhir:ClaimResponse.error [ # 0..* Processing errors
    fhir:ClaimResponse.error.itemSequence [ positiveInt ]; # 0..1 Item sequence number
    fhir:ClaimResponse.error.detailSequence [ positiveInt ]; # 0..1 Detail sequence number
    fhir:ClaimResponse.error.subDetailSequence [ positiveInt ]; # 0..1 Subdetail sequence number
    fhir:ClaimResponse.error.code [ CodeableConcept ]; # 1..1 Error code detailing processing issues
  ], ...;
  fhir:ClaimResponse.totalCost [ Money ]; # 0..1 Total Cost of service from the Claim
  fhir:ClaimResponse.unallocDeductable [ Money ]; # 0..1 Unallocated deductible
  fhir:ClaimResponse.totalBenefit [ Money ]; # 0..1 Total benefit payable for the Claim
  fhir:ClaimResponse.payment [ # 0..1 Payment details, if paid
    fhir:ClaimResponse.payment.type [ CodeableConcept ]; # 0..1 Partial or Complete
    fhir:ClaimResponse.payment.adjustment [ Money ]; # 0..1 Payment adjustment for non-Claim issues
    fhir:ClaimResponse.payment.adjustmentReason [ CodeableConcept ]; # 0..1 Explanation for the non-claim adjustment
    fhir:ClaimResponse.payment.date [ date ]; # 0..1 Expected data of Payment
    fhir:ClaimResponse.payment.amount [ Money ]; # 0..1 Payable amount after adjustment
    fhir:ClaimResponse.payment.identifier [ Identifier ]; # 0..1 Identifier of the payment instrument
  ];
  fhir:ClaimResponse.reserved [ Coding ]; # 0..1 Funds reserved status
  fhir:ClaimResponse.form [ CodeableConcept ]; # 0..1 Printed Form Identifier
  fhir:ClaimResponse.processNote [ # 0..* Processing notes
    fhir:ClaimResponse.processNote.number [ positiveInt ]; # 0..1 Sequence Number for this note
    fhir:ClaimResponse.processNote.type [ code ]; # 0..1 display | print | printoper
    fhir:ClaimResponse.processNote.text [ string ]; # 0..1 Note explanatory text
    fhir:ClaimResponse.processNote.language [ CodeableConcept ]; # 0..1 Language if different from the resource
  ], ...;
  fhir:ClaimResponse.communicationRequest [ Reference(CommunicationRequest) ], ... ; # 0..* Request for additional information
  fhir:ClaimResponse.insurance [ # 0..* Insurance or medical plan
    fhir:ClaimResponse.insurance.sequence [ positiveInt ]; # 1..1 Service instance identifier
    fhir:ClaimResponse.insurance.focal [ boolean ]; # 1..1 Is the focal Coverage
    fhir:ClaimResponse.insurance.coverage [ Reference(Coverage) ]; # 1..1 Insurance information
    fhir:ClaimResponse.insurance.businessArrangement [ string ]; # 0..1 Business agreement
    fhir:ClaimResponse.insurance.preAuthRef [ string ], ... ; # 0..* Pre-Authorization/Determination Reference
    fhir:ClaimResponse.insurance.claimResponse [ Reference(ClaimResponse) ]; # 0..1 Adjudication results
  ], ...;
]

Changes since DSTU2

ClaimResponse
ClaimResponse.status
  • Added Element
ClaimResponse.patient
  • Added Element
ClaimResponse.insurer
  • Added Element
ClaimResponse.payeeType
  • Type changed from Coding to CodeableConcept
ClaimResponse.item.itemSequence
  • Added Element
ClaimResponse.item.adjudication.category
  • Added Element
ClaimResponse.item.adjudication.reason
  • Added Element
ClaimResponse.item.adjudication.amount
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.item.detail.detailSequence
  • Added Element
ClaimResponse.item.detail.noteNumber
  • Added Element
ClaimResponse.item.detail.adjudication
  • Remove BackboneElement
ClaimResponse.item.detail.subDetail.subDetailSequence
  • Added Element
ClaimResponse.item.detail.subDetail.noteNumber
  • Added Element
ClaimResponse.item.detail.subDetail.adjudication
  • Remove BackboneElement
ClaimResponse.addItem.itemSequence
  • Added Element
ClaimResponse.addItem.detailSequence
  • Added Element
ClaimResponse.addItem.subdetailSequence
  • Added Element
ClaimResponse.addItem.service
  • Min Cardinality changed from 1 to 0
  • Type changed from Coding to CodeableConcept
ClaimResponse.addItem.modifier
  • Added Element
ClaimResponse.addItem.fee
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.addItem.noteNumber
  • Added Element
ClaimResponse.addItem.adjudication
  • Remove BackboneElement
ClaimResponse.error.itemSequence
  • Added Element
ClaimResponse.error.detailSequence
  • Added Element
ClaimResponse.error.subDetailSequence
  • Added Element
ClaimResponse.error.code
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/adjudication-error (required)
ClaimResponse.totalCost
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.unallocDeductable
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.totalBenefit
  • Type changed from Quantity{http://hl7.org/fhir/StructureDefinition/Money} to Money
ClaimResponse.payment
  • Added Element
ClaimResponse.payment.type
  • Added Element
ClaimResponse.payment.adjustment
  • Added Element
ClaimResponse.payment.adjustmentReason
  • Added Element
ClaimResponse.payment.date
  • Added Element
ClaimResponse.payment.amount
  • Added Element
ClaimResponse.payment.identifier
  • Added Element
ClaimResponse.form
  • Type changed from Coding to CodeableConcept
  • Remove Binding http://hl7.org/fhir/ValueSet/forms (required)
ClaimResponse.processNote
  • Added Element
ClaimResponse.processNote.number
  • Added Element
ClaimResponse.processNote.type
  • Added Element
ClaimResponse.processNote.text
  • Added Element
ClaimResponse.processNote.language
  • Added Element
ClaimResponse.communicationRequest
  • Added Element
ClaimResponse.insurance
  • Added Element
ClaimResponse.insurance.sequence
  • Added Element
ClaimResponse.insurance.focal
  • Added Element
ClaimResponse.insurance.coverage
  • Added Element
ClaimResponse.insurance.businessArrangement
  • Added Element
ClaimResponse.insurance.preAuthRef
  • Added Element
ClaimResponse.insurance.claimResponse
  • Added Element
ClaimResponse.ruleset
  • deleted
ClaimResponse.originalRuleset
  • deleted
ClaimResponse.organization
  • deleted
ClaimResponse.item.sequenceLinkId
  • deleted
ClaimResponse.item.adjudication.code
  • deleted
ClaimResponse.item.detail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.adjudication.code
  • deleted
ClaimResponse.item.detail.adjudication.amount
  • deleted
ClaimResponse.item.detail.adjudication.value
  • deleted
ClaimResponse.item.detail.subDetail.sequenceLinkId
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.code
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.amount
  • deleted
ClaimResponse.item.detail.subDetail.adjudication.value
  • deleted
ClaimResponse.addItem.sequenceLinkId
  • deleted
ClaimResponse.addItem.noteNumberLinkId
  • deleted
ClaimResponse.addItem.adjudication.code
  • deleted
ClaimResponse.addItem.adjudication.amount
  • deleted
ClaimResponse.addItem.adjudication.value
  • deleted
ClaimResponse.addItem.detail
  • deleted
ClaimResponse.error.sequenceLinkId
  • deleted
ClaimResponse.error.detailSequenceLinkId
  • deleted
ClaimResponse.error.subdetailSequenceLinkId
  • deleted
ClaimResponse.paymentAdjustment
  • deleted
ClaimResponse.paymentAdjustmentReason
  • deleted
ClaimResponse.paymentDate
  • deleted
ClaimResponse.paymentAmount
  • deleted
ClaimResponse.paymentRef
  • deleted
ClaimResponse.note
  • deleted
ClaimResponse.coverage
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON.

 

Alternate definitions: Master Definition (XML, JSON), XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

13.7.2.1 Terminology Bindings

PathDefinitionTypeReference
ClaimResponse.status A code specifying the state of the resource instance.RequiredFinancial Resource Status Codes
ClaimResponse.outcome The result of the claim processingRequiredClaim Processing Codes
ClaimResponse.payeeType A code for the party to be reimbursed.ExampleClaim Payee Type Codes
ClaimResponse.item.adjudication.category The adjudication codes.ExampleAdjudication Value Codes
ClaimResponse.item.adjudication.reason The adjudication reason codes.ExampleAdjudication Reason Codes
ClaimResponse.addItem.service Allowable service and product codes.ExampleUSCLS Codes
ClaimResponse.addItem.modifier Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.ExampleModifier type Codes
ClaimResponse.error.code The adjudication error codes.ExampleAdjudication Error Codes
ClaimResponse.payment.type The type (partial, complete) of the paymentExampleExample Payment Type Codes
ClaimResponse.payment.adjustmentReason Payment Adjustment reason codes.ExamplePayment Adjustment Reason Codes
ClaimResponse.reserved For whom funds are to be reserved: (Patient, Provider, None).ExampleFunds Reservation Codes
ClaimResponse.form The forms codes.ExampleForm Codes
ClaimResponse.processNote.type The presentation types of notes.RequiredNoteType
ClaimResponse.processNote.language A human language.Extensible, but limited to All LanguagesCommon Languages

13.7.3 Search Parameters

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

NameTypeDescriptionExpressionIn Common
createddateThe creation dateClaimResponse.created
dispositionstringThe contents of the disposition messageClaimResponse.disposition
identifiertokenThe identity of the claimresponseClaimResponse.identifier
insurerreferenceThe organization who generated this resourceClaimResponse.insurer
(Organization)
outcometokenThe processing outcomeClaimResponse.outcome
patientreferenceThe subject of care.ClaimResponse.patient
(Patient)
payment-datedateThe expected paymentDateClaimResponse.payment.date
requestreferenceThe claim referenceClaimResponse.request
(Claim)
request-providerreferenceThe Provider of the claimClaimResponse.requestProvider
(Practitioner)
statustokenThe status of the claim responseClaimResponse.status